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Digitized  by  the  Internet  Archive 

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7 


[ 


THE 


PRINCIPLES  AND  PRACTICE 


DENTISTRY. 


STANDARD  BOOKS  ON  DENTISTRY 

FOR  DENTAL  STUDENTS  AND  PRACTITIONERS. 


Harris. — The  Principles  and  Practice  of  Dentistrj'.     nth   Edition. 

By  Prof.  F.  J.  S.  Gorgas.     7.)6  IlUis.  CI.,  $6.50;  Sh.,  $7.50 

Harris.— Dictionary  of  Medicine,  Dentistry,  and  Collateral  Sciences. 

4th  Edition.  By  Prof.  F.  J.  S.  Gorgas.  CI.,  36.50;  Sh.,  J7.50 
Richardson.— Mechanical  Dentistrj'.  3d  Ed.  CI.,  $4.00;  Sh.,  ^4.75 
Potter. — Compend  of  Anatomy.     Illustrated.  gi.oo 

Taft.— Operative  Dentistry.  4th  Ed.  136IIIUS.  CI.,  §4.25;  Sh.,  $5.00 
Leber  and  Rottenstein. — Dental  Caries.  Paper,  75  c;  CI.,  J1.2S 
Sansom. — Chloroform:  Its  Administration,  etc.  Pa.,  75c;  CI., $1.25. 
White.— The  Mouth  and  Teeth.     Illus.  Paper,  .30;  CI.,  .50 

Barrett.— Dental  Surgerj'.  To  be  ready  February,  1883. 

Coles. — Deformities  of  the  Mouth.     3d  Ed.     Illustrated.  fA-%° 

Coles. — Dental  Students'  Note  Book.  $1.00 

Gorgas. — Dental  Materia  Medica  and  Therapeutics.  $3.00 

Heath. — Injuries  and  Diseases  of  the  Jaws.     3d  Ed.     Illus.  $4.50 

Kirkes. — Physiology,     nth  Ed.     Illustrated.  ?5.oo 

Tomes. — Dental  Surgery.     Illus.     New  Ed.  In  Press. 

Tomes. — Dental  Anatomy.     2d  Ed.     Illus.  $4.25 

Stocken. — Dental  Materia  Medica.     3d  Edition.  ^2.50 

Turnbull. — Artificial  Anesthesia.     Illus.  $1.50 

Yeo. — Manual  of  Physiology.     300  Illus.  CI.,  $4.00;  Sh.,  $5.00 

Hunter. — Mechanical  Dentistry.     100  Illus.  ^1.50 

Flagg. — Plastics  and  Plastic  Filling.    2d  Ed.  J4.00 

Potter. — Compend  of  Materia  Medica.     Illustrated.  gi.oo 

Brubaker. — Compend  of  Physiology.    2d  Ed.  $1.00 

Holden. — Anatomy.     5th  Ed.     208  Illus.  Cl.,?5.oo;  Sh.,$6.oo. 

P.  BLAKISTON,  SON  &  CO., 

Medical  and  Dental  Booksellers, 

1012  WALNUT  ST.,  PHILADELPHIA. 
SIS'  Catalogues  0/ Medical  and  Dental  Books  sent  upon  application. 


Drawn  by  J.L  Wiiliaras  ^fcw  [lave:.,  Coi.n.ti-orr  specimen  cut-J;roui.: 
,  human  embryo,  ■ma^jiijied.lifei'.iy-five  diameters. 

1  .Germs  of  upper  and  lov">- '•'■;•  '. -:■    "••'.' <--- 

S.Mecksls  carLila5e. 

3.Ccrm.neiiciiig  o.^-siiiCdL-v-:. :     .l-  ...    -;--x!:.- 

4. Commencing  ossification  of  superior  niaxi!!.'. 

5  .Tongxie. 

6  &?.  Gsnio-|lossal  and  gemo-hyoid  muscles,  cut  trar.i?verselv 


THE 


PRINCIPLES  AND  PRACTICE 


DENTISTKT 


INCLUDING 


ANATOMY,   PHYSIOLOGY,   PATHOLOGY,   THERAPEUTICS, 
DENTAL  SURGERY  AND  MECHANISM. 


CHAPIN  A.  HARRIS,  M.D.,  D.D.S., 

LATE   PRESIDENT   OF   THE   BALTIMORE   DENTAL   COLLEGE,   AUTHOR    OF   "DICTIONARY  OF   MEDICAL 
TERMINOLOGY  AND   DENTAL  SUHGEEY." 


(BUvtntU  ^tUtidu. 


TIEVISED  AND  EDITED  BY 
FERDINAND  J.  S.  GORGAS,  A.M.,  M.D.,  D.D.S., 

AUTHOR   or  "DENTAL    MEDICINE,"   EDITOR   OF   HARRIS'    "DICTIONARY    OF    MEDICAL    TERMINOLOGY    AND    DENTAL 

SURGERY,"   PROFESSOR   OF  THE   PRINCIPLES   OF   DENTAL   SCIENCE,   DENTAL   SURGERY   AND 

DENTAL  MECHANISM   IN   THE   UNIVERSITY   OF   MARYLAND. 


WITH   TWO  FULL-PAGE   PLATES 

AND 

SEVEN  HUNDRED  AND  FORTY-FOUR   OTHER  ILLUSTRATIONS. 


PHILADELPHIA : 

P.    BLAKISTOK,    SON    &   CO., 

No.  1012  \Valnut  Street. 
1885. 


% 


Entered  according  to  Act  of  Congress,  in  the  year  1885,  by 

P.  BLAKISTON,  SON  &  CO., 

In  tlie  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


WM.  F.  FELL  &  CO., 

Printers, 

1220-1224  Sansom  St.,  Philadelphia. 


TO   THE 

PRACTITIONERS  AND  STUDENTS 

OP 


DENTISTRY, 


THIS  VOLUME 


IS  RESPECTFULLY  DEDICATED. 


EDITOR'S  PREFACE 

TO    THE    ELEVENTH    EDITION. 


THE  first  edition  of  Chapin  A.  Harris'  '^  Principles  and  Prac- 
tice of  Dentistry"  was  published  in  1841,  and  from  that  date 
it  has  been  the  principal  text-book  in  all  dental  schools. 

The  last  or  tenth  revision  was  issued  under  the  careful  supervision 
of  the  late  Professor  Philip  H.  Austen,  m.d.,  d.d.s.,  assisted,  in  the 
parts  relating  to  anatomy  and  physiology,  by  Dr.  Thos.  S.  Latimer, 
and  in  parts  relating  to  pathology  and  surgery,  by  the  editor  of  the 
present  edition.  ,As  the  ten  years  prior  to  this  revision  had  nearly 
revolutionized  dental  mechanism,  Professor  Austen  found  it  neces- 
sary to  almost  re-write  the  portion  of  the  work  relating  to 
"  Mechanics,"  and  its  superior  excellence  was  universally  acknow- 
ledged. 

Nearly  fourteen  years  having  elapsed  since  this  was  done,  the 
rapid  advances  made  during  this  period  in  Dental  Histology, 
Pathology,  Surgery,  and  also,  to  a  considerable  degree,  in  Mechan- 
ism, have  necessitated  another  revision,  and  at  the  request  of 
the  author's  family,  and  of  the  publishers,  the  editor  has  alone 
undertaken  the  task  of  revision,  and  the  present  edition  is  the 
result  of  more  than  a  year's  labor.  This  duty  has  been  assumed 
with  the  hope  that  an  experience  of  over  a  quarter  of  a  century  as 
a  teacher  in  dental  schools,  and  also  as  a  dental  practitioner,  may 
have  furnished  the  qualifications  for  such  an  undertaking. 

The  time  which  has  elapsed  since  the  first  appearance  of  the 
tenth  edition  has  necessitated  a  greater  revision  of  this  work  than 
has  been  the  case  with  any  former  edition,  and  the  task  of  preparing 
an  entirely  new  work  would  have  been  no  greater. 

Considerable  changes  have  been  made  in  the  general  arrangement 
of  subjects  ;  a  number  of  entirely  new  chapters  have  been  added  in 
the  consideration  of  subjects  not  even  alluded  to  in  former  editions; 
additions  have  also  been  made  to  the  text  of  nearly  ev^ery  chapter, 
some  of  the  latter  being  far  in  excess  of  the  original  text. 

XV 


xvi  EDITORS    PREFACE. 

The  number  of  illustrations  has  been  greatly  increased,  and  the 
new  matter  now  inserted  has  brought  the  work  fully  up  to  the 
time  of  its  publication. 

Obsolete  theories  and  processes,  together  with  unimportant 
details,  have  been  omitted,  and  more  useful  matter  substituted. 
The  aim  of  the  editor  has  been  to  meet  the  demands  of  the  present 
advanced  state  of  dental  science. 

The  new  matter  added  includes :  The  Development  of  the 
Bones  of  the  Head  and  Face;  Temporo-Maxillary  Articulation ; 
Description  of  Mucous  Membrane;  The  Origin  and  Development 
of  the  Teeth;  Analyses  of  Tooth  Structures;  Secondary  Dentine; 
Dentition  ;  Calcification  and  Decalcification  of  the  Teeth;  Alveolar 
Pyorrhoea;  Aphthous  Stomatitis ;  Thrush  ;  Sanguinary  Calculus; 
Malformed  Teeth  ;  Effects  of  Syphilis  upon  the  Dental  Structures ; 
Caries  of  the  Maxillary  Bones ;  Sensitive  Dentine ;  Theories  as  to 
the  Cause  of  Dental  Caries ;  Treatment  of  Dental  Caries ;  New 
Methods,  Materials  and  Instruments  Employed  in  Filling  Teeth 
and  other  Operations;  Electric  ]\[outh  Lamp;  Electric  Mallet; 
Dental  Engines  and  Attachments ;  Rubber  Dam  Appliances ; 
Treatment  and  Appliances  for  Correcting  Irregularity  of  the 
Teeth;  Contour  Fillings;  Replantation  and  Transplantation  of 
Teeth ;  Different  Methods  of  Inserting  Artificial  Crowns  on  Natural 
Roots  ;  Bridge  Work;  General  and  Local  Anaesthetic  Agents;  Im- 
proved Forceps  ;  Xew Materials  and  Trays  for  Impressions;  Artic- 
ulators ;  Blowpipes ;  Furnaces ;  Celluloid  ;  2s  ew  Apparatus  for 
Vulciiuizing  Rubber  and  Moulding  Celluloid;  Repairing  Vul- 
canite; Duplicating  Dentures;  Theory  of  Vulcanizing;  Regu- 
lators; Gold  Alloy  and  other  Cast  Bases ;  Temperament  in  Relation 
to  Natural  and  Artificial  Teeth;  Improvements  in  Porcelain  Teeth  ; 
New  Splints  for  Fracture  of  the  Jaws;  etc.;  etc.;  etc.; 

The  editor  desires  to  acknowledge  his  indebtedness  to  Drs.  George 
B.  Snow,  James  H.  Harris,  Charles  L.  Steel,  W.  Storer  How,  and 
D.  Genese,  for  valuable  suggestions;  and  also  to  the  writings  of 
Drs.  James  W.  White,  Frank  Abbott,  J.  Foster  Flagg,  John 
Tomes,  Charles  Tomes,  Henry  Sewell,  Henry  W.  Williams,  C.  N. 
Peirce,  W.  D.  Miller,  G.  V.  Black,  George  Watt,  J.  L.  Williams, 
James  B.  Dexter,  Norman  W.  Kingsley,  Theo.  F.  Chupein,  J.  N. 
Farrar,  W.  C.  Barrett,  J.  D.  Hutchinson,  W.  G.  A.  Bonwill,  A.  W. 
I  Harlan,  C.  T.  Stockwell,  the  late  M.  A.  Dean,  M.  H.  Webb,  and 

\  others.     The  courtesy  of  The  S.  S.  White  Dental  Manufacturing 


EDITORS   PREFACE.  xvii 

Company,  Johnson  &  Lund,  Snowden  &  Cowman,  Codman  & 
Shurtleff,  The  Buffalo  Dental  Manufacturing  Company,  Spencer 
&  Crocker,  Ransom  &  Randolph,  and  Gideon  Sibley,  and  Dr. 
Norman  W.  Kingsley,  is  acknowledged,  for  the  use  of  many  valu- 
able wood-cuts. 

The  Eleventh  Edition  of  Harris'  "  Principles  and  Practice  of 
Dentistry  "  is  submitted  to  the  profession,  with  a  hope  that  it  will 
be  found  a  useful  elementary  treatise,  a  text-book  for  the  student, 
and  a  reliable  guide  for  the  dental  practitioner. 

FERDINAND  J.  S.  GORGAS. 

Baltimore,  January,  1885. 


PREFACE 

TO   THE   SECOND   EDITION. 


TN  submitting  to  the  profession  a  Second  Edition  of  his  Dental 
-*-  Practice,  the  author  is  happy  to  avail  himself  of  the  oppor- 
tunity to  express  his  grateful  appreciation  of  the  approbation  which 
the  First  has  received.  He  trusts  that  the  additions  which  he  has 
made  to  the  primary  work  will  make  the  one  now  presented  still 
more  acceptable.  The  alteration  in  the  plan,  which  has  resulted 
from  the  effort  at  improvement,  has,  however,  rendered  a  slight 
change  of  title  necessary,  in  order  to  express  the  character  of  the 
present  book. 

In  the  First  Edition  the  Anatomy  of  the  Mouth  was  omitted, 
because  a  thorough  knowledge  of  it  can  be  obtained  from  works  on 
General  Anatomy.  But  it  has  been  suggested  that  such  works  may 
not  be  at  hand  when  wanted  by  the  dental  student,  and  the  author 
has  thought  it  better  to  furnish  a  description  of  the  several  structures 
which  enter  into  the  formation  of  this  cavity.  He  has,  however, 
confined  himself  to  brief  expositions  of  the  parts;  not  wishing  to 
encumber  the  work,  or  distract  the  student  with  the  consideration 
of  matters  foreign  to~the  purpose  for  which  it  was  written,  and  for 
which,  he  trusts,  it  will  be  read.  He  is  indebted  to  Bourgery's 
Anatomy,  Quain  and  Wilson's  Anatomical  Plates,  Wilson's 
Anatomy,  and  Smith  and  Horner's  Anatomical  Atlas,  for  a  number 
of  the  illustrations  used  in  this  part  of  the  work. 

The  Second  and  Fifth  Parts  embody  the  substance  of  two  papers 
by  the  author,  which  were  written  subsequently  to  the  publication 
of  the  first  edition.  The  subjects  of  them  came  properly  within  the 
plan  of  the  present  work. 

The  object  of  the  author  in  the  preparation  of  this  edition  has 
been  to  provide  a  thorough  elementary  treatise  on  Dental  Medicine 
and  Surgery,  which  might  be  a  text-book  for  the  student  and  a 
guide  to  the  more  experienced  practitioner ;  and  he  hopes  that  the 
modifications  he  has  introduced,  and  the  additions  he  has  made, 
will  entitle  it  to  be  so  considered,  at  least,  until  an  abler  hand  shall 
prepare  a  better. 

CHAPIN  A.  HARRIS,  M.D.,  D.D.S. 
xix 


CONTENTS. 


INTRODUCTION. 

PART  FIRST. 

ANATOMY  AND  PHYSIOLOGY. 
CHAPTER  I. 

PAOE 

Development  of  the  Cell  Doctrine 41 

CHAPTER  11. 

Anatomy  and  Physiology  of  the  Mouth 54 

CHAPTER  III. 
Osteology 55 

CHAPTER  IV. 

Bones  of  the  Head  and  Face. 

Development  of  the  Bones  of  the  Head  andFace 57 

Superior  Maxillary 61 

Inferior  Maxillary 65 

Palate 68 

CHAPTER  V. 

Muscles  of  the  Mouth  and  Face. 

Myology 70 

Nasal  Group  of  Muscles "^2 

Superior  Maxillary  Group 73 

Inferior  Maxillary  Group 73 

Temporo-Maxillary  Group '4 

Pter3'go-Maxillary  Group 76 

Lingual '' 

Pharyngeal '° 

Palatal 79 

Soft  Palate,  Fauces  and  Tonsils 81 

Articulations— Temporo-Maxillary  Articulation 81 

xxi 


XX 11  CONTENTS. 

CHAPTER  VI. 

Blood  Vessels  of  the  Mouth  and  Face.  paoe 

Internal  Carotid  Artery 82 

External  Carotid  Artery  and  Branches 83 

Veins 87 

CHAPTER   VII.     ■ 

Nertes  of  the  Mouth  and  Face. 

Fifth  Pair— Trigemini 87 

Ophthalmic  Branches 88 

Superior  Maxillary  Branches 89 

Inferior  Maxillary  Branches 91 

Facial  Nerve  and  Branches 92 

CHAPTER  A^III. 

Salitart  Glaxds,  Tongue,  Gums. 

Parotid  Gland  and  Saliva 95 

Submaxillary  Glands 97 

Sublingual  and  Mucous  Glands , 98 

Saliva  from  all  Glands 98 

Tongue 99 

Mucous  Membrane 100 

Gum  and  Dental  Periosteum 103 

Relations  of  the  Mouth,  Anatomical  104 

"  "  Physiological 105 

CHAPTER  IX.  ^ 

The  Teeth. 

Deciduous  or  Temporary  Teeth 107 

Permanent  Teeth — Incisors 107 

Cuspids  or  Canines 109 

Bicuspids  or  Pre-Molars 110 

Molars Ill 

Articulation  with  Maxillae 112 

Comparison  of  Temporary  with  Permanent 113 

Antagonism  of  Upper  and  Lower 113 

CHAPTER  X. 

Origin  axd  Formation  of  the  Teeth. 

Condition  of  the  Jaws  of  the  Embryo  at  the  Peiiod  of  the  Formation 

of  the  Dental  Follicle 117 

Development  of  the  Enamel 117 

Development  of  the  Dentine 125 

Development  of  the  Cementum 129 

Origin  of  the  Permanent  Teeth 130 

Dental  Pulp 134 


CONTENTS.  xxiii 

CHAPTER  XI. 

Osseous  Tooth  Structures  page 

Enamel 137 

Dentine 140 

Cementura 147 

Osteo-  or  Secondary  Dentine 149 


PART  SECOND. 

PATHOLOGY  AND  THERAPEUTICS. 

CHAPTER  I. 

General  Considerations 153 

Temperament  in  Relation  to  the  Teeth 155 

CHAPTER  II. 

Dentition — First,  Second  and  Third 162 

Classification  of  Teeth 176 

CHAPTER  III. 

Diseases  of  the  Mucous  Membrane. 

Simple  or  Catarrhal  Stomatitis 184 

Ulcerous  Stomatitis 185 

Aphthous  Stomatitis 187 

Thrush 188 

Gangrenous  Stomatitis 189 

Mercurial  Stomatitis 193 

Scorbutus — Scurvy 194 

CHAPTER  IV. 

Diseases  of  the  Gums. 

General  Considerations 196 

Inflammations,  Acute  and  Chronic 203 

Hypertrophy 212 

Mercurial  Inflammation , 214 

Ulceration,  with  Exfoliation  of  Bone 217 

Alveolar  Pyorrhoea 219 

Adhesion  of  Gums  to  Cheek 222 

CHAPTER  V. 

Tumors  of  the  Mouth  and  Jaws 223 

Cystic  Tumors — Dentigerous  Cysts 233 


XXIV  CONTENTS. 

CHAPTER  VI. 

Salivary  Calculus.  page 

Classification  of  Varieties 240 

Chemical  Composition 245 

Origin  and  Deposition 246 

Effects  upon  Teeth,  Gums,  and  Alveoli 248 

Manner  of  Removing 249 

Sanguinary  Calculus 251 

Mucous  Deposits  upon  Teeth 252 

CHAPTER  VII. 
The  Fluids  of  the  Mouth 254 

CHAPTER  VIII. 

Characteristics  of  t5e  Lips 256 

'  CHAPTER  IX. 

Characteristics  of  the  Tongue 258 

CHAPTER  X. 

Diseases  of  the  Dental  Pulp. 

General  Remarks 262 

Irritation 263 

Inflammation 265 

Causes  and  Treatment  of  Odontalgia 273 

Spontaneous  Disorganization 280 

Fungous  Growth 281 

Ossification 282 

Destruction  and  Removal  of  Pulp 283 

CHAPTER  XI. 

Sensitiveness  of  Dentine 289 

CHAPTERS  XII-XVI. 

Diseases  of  the  Alveolar  Processes. 

XII.  Periostitis 293 

XIII.  Abscess 297 

XIV.  Necrosis  and  Exfoliation 306 

XV.  Absorption 310 

XVI.  Hypertrophy  of  Walls   of  Cavities 313 

CHAPTERS  XVII-XXIV. 

Diseases  of  the  Teeth. 

XVII.  Atrophy 314 

XVIII.  Necrosis 321 


CONTENTS.  XXV 

PAQE 

XIX.  Exostosis 324 

XX.  Denudation 327 

XXI.  Chemical  Abrasion 328 

XXII.  Mechanical  Abrasion 330 

XXIII.  Fractures  and  Other  Injuries 331 

XXIV.  Dental  Caries  : 

Classification 334 

Liability  of  Teeth  to  Caries 336 

Causes  of  Caries 341 

Prevention  of  Caries 348 


CHAPTER  XXV. 

Malformed  Teeth 350 


PART  THIRD. 

DENTAL  SURGERY. 

CHAPTER  I. 
Irregularity  of  the  Teeth 363 


CHAPTER  II. 

Treatment  of  Dental  Caries 406 

Treatment  of  Superficial  Caries  by  the  Use  of  Files,  Enamel  Chisels, 

Disks,  etc 407 

Separation  of  the  Teeth 419 

Treatment  of  Deep-seated  Caries 428 

Materials  Employed  for  Filling  Teeth 429 

Gold:  Non-Cohesive  Foil 429 

Cohesive  Foil 430 

Crystal  or  Sponge 481 

Platinum 432 

Tin  Foil  and  Fusible  Alloys 432 

Amalgam 433 

Textile  Metallic  Filling 436 

Guttapercha:  Hill's  Stopping 437 

Zinc  Preparations— Oxychloride  and  Oxyphosphate 438 

Formation  of  the  Cavity 440 

Instruments  used — Dental  Engine,  etc 445 

Rules  for  Shaping  Cavity 455 

Protection  against  Saliva — Rubber  Dam,  etc 458 

Drying  the  Cavity 466 


XXVI  CONTENTS. 

PAGE 

Filling  the  Cavity:  Instruments  used 467 

Preparation  and  Use  of  Materials 470 

Non  Cohesive  Foil:  Rope  and  Folds,  Ribbons,  Cylinders,  etc.  470 

Cylinder  Filling 473 

Redman's  Cylinders 475 

Herbst  Method 477 

Pellets,  Mats  and  Blocks 479 

Cohesive  Foil 479 

Heavy  Foil '. 482 

Crystal  or  Sponge  Gold 483 

Condensation   of   Filling   with     Mallet — Automatic   and   Electric 

Mallet,  etc 485 

Finishing  Surface  of  Filling 491 

Non-Conductors  over  Sensitive  Pulp 493 

Filling  Particular  Cavities  in 495 

Superior  Incisors  and  Cuspids 496 

Superior  Bicuspids  and  Molars 504 

Inferior  Incisors  and  Cuspids 511 

Inferior  Bicuspids  and  Molars 513 

Contour  Fillings 516 


CHAPTER  III. 

Filling  Teeth  Over  Exposed  Pulps 528 

Non-Conductors  and  Protectors 530 

Different  Methods  and  Materials  for  Capping 530 


CHAPTER  IV. 

Filling  Pulp  Chamber  and  Canals  of  Teeth. 

General  Considerations 535 

Preparation  of  Cavity  and  Root 538 

Operation  of  Filling 539 


CHAPTER  V. 

Extraction  of  Teeth. 

General  Remarks 542 

Indications  for  Extraction 544 

Instruments 546 

Key  of  Garengeot 546 

Manner  of  Using 547 

Forceps:  Various  Forms 549 

Manner  of  Using  Gum  Lancets 559 

Extraction  of  Roots ,• 563 

Extraction  of  the  Temporary  Teeth 570 

Hemorrhage  after  Extraction  and  Treatment 571 


CONTENTS.  XXvii 

CHAPTER  VI. 

Use  of  An.esthetics  in  Extraction   op  Teeth.  page 

General  Anesthesia  by  Ether 574 

Cliloroform 575 

Nitrous  Oxide 575 

Other  Anesthetics 580 

Local  Anassthesia  by  Cold 581 

Electro-Magnetism 583 

Spray  Apparatus 585 

Obtunding  Mixtures #., .• 535 

Hydi'ochlorate  of  Cocaine 586 

Rapid  Breathing  as  a  Pain  Obtunder 586 

CHAPTER  Vn. 

Replantation  and  Transplantation  or  Teeth 587 

CHAPTER  VIII. 

Dislocation  and  Fracture  of  the  Jaw...... 590 

CHAPTER  IX. 
Diseases  op  the  Antrum 597 

CHAPTER  X. 

Caries  of  the  Maxillaey  Bones 619 


PART  FOURTH. 

DENTAL  MECHANICS. 
Classification  of  Operations 625 

CHAPTER  I. 

Prosthesis  of  Dental  Organs 627 

CHAPTER  11. 

Substances  used  as  Dental  Substitutes. 

Human  Teeth 631 

Teeth  of  Cattle 632 

Elephant  and  Hippopotamus  Ivory 633 

Porcelain,  or  Incorruptible  Teeth 633 


XXVIU  CONTENTS. 

CHAPTER  III. 

DiFJ'ERENT  Methods  of  Inserting  Teeth.  page 

Placed  upon  Natural  Roots 636 

Secured  by  Clasps 638 

Retained  by  Spiral  Springs 640 

Held  by  Atmospheric  Pressure 640 

CHAPTER  IV. 

Preparatory  Treatment  of  the  Mouth 643 

CHAPTER  V. 

Preparation  of  Natural  Root  and  Attachment  of  Artificial  Crown...  647 
Bridge  and  Graft  Work 685 

CHAPTER  VI. 

Refining  and  Alloying  Gold  and  Calculating  Fineness  of  Gold  Plate. 

Quality  of  Gold  for  Plate 687 

Refining  Gold 689 

Alloying  Gold 694 

Calculating  Fineness  of  Gold  Plate 697 

CHAPTER  VII. 

Gold  Plate,  Spiral  Springs,  Gold  Solder. 

Ingot  Moulds 698 

Rolling  Mills 700 

Gauge  and  Draw  Plates 702 

Gold  Solder 703 

CHAPTER  VIII. 

Cups  and  Materials  for  Impressions  of  the  Mouth — Plaster  Models. 

Impression  Cups 705 

Impression  Materials 708 

Comparative  Value 715 

Plaster  Models 718 

CHAPTER  IX. 

Metallic  Dies  and  Counter-Dies — Process  or  Swaging. 

Methods  of  Making  Dies  and  Counter-Dies 724 

Metals  used  for  Dies  and  Counter-Dies 729 

Processes  of  Swaging 735 


CONTENTS.  Xxix 

CHAPTER  X. 

TAOE 

Articulation,  or  Antagoncsm  oi-^  Teeth 740 

CHAPTER  XI. 

Prixciples  and  Appliances  of  Soldering. 

Principles  of  Soldering 748 

Soldering  Lamps 749 

Blowpipes  ;  Mouth 750 

Self-acting "752 

Mechanical 753 

Hydrostatic 755 

Other  Appliances  of  Soldei-ing  756 

CHAPTER  XII. 

Adjdstment  of  Porcelain  Teeth  to  the  Plate— Finishing  Process. 

Varieties  of  Porcelain  Teeth 759 

Dental  Lathes 761 

Grinding  and  Arranging  Teeth 764 

Investing  and  Backing  Teeth 767 

Soldering  Backings  to  Teeth  and  Plate 774 

Finishing  Process 775 

CHAPTER   XIII. 

Retention  of   Base  Plates   in  the  Mouth — Their  Size  and  Form  of  Out- 
line— Materials  of  Swaged  Plates — Continuous  Gum  Work. 

Different  Methods  of  Retention 779 

Spiral  Springs 779 

Clasps:  Utility  and  Application 781 

Shape  and  Adjustment 783 

Partial  Clasps  or  Stays 788 

Size  and  Outline  of  Clasp  Plate- 789 

For  Upper  Incisors , 790 

For  Upper  Bicuspids 792 

For  Alternate  Spaces 794 

Atmospheric  Pressure  Principle 796 

.    Adhesion  of  Contact 799 

Vacuum  Cavity 802 

Various  Materials  of  Swaged  Plates 806 

Continuous  Gum  Work 807 

CHAPTER  XIV. 

Moulded  Plates,  or  Plastic  Work— Ceramo-Plastic  Work. 

Classification  of  Plastic  Work 816 

Comparison  of  Varieties 817 

Ceramo-Plastic  Work 818 


XXX  CONTENTS. 

CHAPTER  XV. 

Metallo- Plastic  Work— Vulcano-Plastic  Work.  page 

Tin  and  its  Alloys 819 

Cheoplastic  Process 820 

Stanno- Plastic  Process 821 

Aluminum 829 

Refining  Aluminum 830 

Swaged  Aluminum  Plates 831 

Gold  Alloy  Cast  Base— Reese's , 832 

-  Vulcano-Plastic  Work.; 837 

Corallite 838 

Vulcanite:  History 889 

Composition  and  Varieties 840 

Effect  of  Vermilion 841 

Vulcano-Plastic  Process  :  Impressions 842 

Models  and  Articulators 843 

Selection  and  Arrangement  of  Teetli 844 

Forms  of  Vulcanizer......... 849 

Thermometers  and  Gas  Regulator 857 

Vulcanizing  Flasks 861 

Forms  of  Flask 862 

Preparation  and  Packing  of  Matrix 862 

Time  of  Vulcanizing 869 

Finislii ng  Process 870 

Repairing  and  Refitting  Vulcanite  Plates 874 

Vulcanite  Attachment  of  Teeth  to  Swaged  Plates 885 

Use  of  Vulcanite  for  Pivot  Tee'h 678 

Directions  to  Patients 891 

General  Remarks  on  Value  of  Vulcanite 891 

Celluloid 893 

History  and  Composition,  and  Preparation 898 

Different  Processes  and  Apparatus  by  which  Celluloid  is  Moulded  893 

Finishing  Process 905 

Repairing 905 

New  Mode  Continuous  Gum 908 

Dr.  Genese's  Process 909 

General  Directions  for  Working  Celluloid 912 

Zylonite 918 

CHAPTER  XVI. 

Composition,  Manufacture,  and  Esthetics  of  Porcelain  Teeth. 

General  Considerations 914 

Porcelain  Materials  :   Silica,  Feldspar ,  915 

Kaolin:    Coloring  Materials 916 

Formulas  for  Body  and  Enamel 917 

Process  of  Manufacture  of  Dental  Porcelain 918 

^Esthetics  of  Dental  Porcelain,  with 921 

Illustrations  of  Form  and  Arrangement 922 


CONTENTS.  XXxi 

PAOK 

Carving  Blocks  for  Special  Cases 'J36 

Dr.  Calvert's  Method 940 

Porcelain  Plates — Ceramo-Plastic  Work 942 

CHAPTER   XVII. 

Defects  op  the  Palatine  Organs. 

Classification  and  Description 944 

Fissure  of  the  Soft  Palate 945 

Staphylorraphy  :  History 948 

Early  Form  of  Operation 951 

Mr.  Cartwright's  Preparation  of  Patient 953 

Sir  Wm.  Fergusson's  Operation 955 

Fissure  of  Hard  and  Soft  Palate 957 

Obturators 961 

Kingsley's  Artificial  Palates 965 

Replacing  Accidental  Defects 969 

Replacing  Congenital  Defects 970 

Obturator  and  Palate  Combined 974 

Construction  of  Artificial  Palates 977 


INTRODUCTION.* 


T\ENTISTRY  is  the  Science  and  Art  of  Medicine  applied  to  the 
-^  Dental  Organs.  Placed  at  the  beginning  of  the  alimentary 
canal,  these  organs  hold  an  important  relation  to  the  digestive 
function,  and  through  it,  to  the  entire  body.  They  have  also 
inseparable  connections  with  the  nervous,  circulatory  and  respira- 
tory systems.  Hence,  whilst  their  preservation  constitutes  an 
important  Art  in  medicine,  the  Science  which  teaches  their  struc- 
ture, functions,  diseases  and  treatment  must  necessarily  be  compre- 
hensive. It  must  include  those  sciences  which  lie  at  the  foundation 
of  all  medical  art,  and  embrace  so  much  of  physical,  mechanical 
and  aesthetic  science  as  its  specific  duties  demand. 

The  Anatomy,  Physiology  and  Pathology  of  dentistry  diifer  in 
no  respect  from  that  taught  in  medical  schools.  The  limits  of  a 
special  text-book  or  curriculum  of  study,  or  a  curtailment  of  the 
term  of  preparation  may  require  the  omission  of  some  details,  to 
give  opportunity  for  a  fuller  exposition  of  others ;  but  a  dentist's 
knowledge  of  these  fundamental  sciences  admits  no  limitation, 
except  that  imposed  by  mental  capacity.  A  single  volume  upon 
the  '^ Principles  and  Practice  of  Dentistry"  must  of  necessity  be 
rigidly  eclectic  in  those  sciences,  each  of  which  occupies  many 
volumes  for  its  full  exposition ;  whilst  it  must  give,  in  complete 
detail,  all  applications  of  science  to  its  specific  duties.  Again, 
the  eclecticism  of  teaching,  both  in  the  office  and  the  college,  is 
dependent  upon  the  time  over  which  it  extends.  Thus  neither 
printed,  oral,  nor  demonstrative  systems  of  instruction  can  be  taken 
as  any  correct  measure  of  the  amount  of  knowledge  essential  to 
professional  excellence ;  for,  in  most  cases,  the  knowledge  thus 
gained  is  insufficient  to  give  full  value  to  the  subsequent- lessons 
of  experience.  The  problem  of  professional  education  is  one  of 
difficult  solution.     While  European  systems  seek  to  make  "ex- 

*  This  excellent  introductory  Chapter  was  prepared  for  the  tenth  edition  of 
this  work,  by  the  late  Professor  P.  H.  Austen,  the  editor  of  that  edition. 
3  xxxiii 


XXXIV  INTEODUCTION. 

perts"  of  students,  American  systems  are  content  to  make  them 
'^  experimenters."  The  Old  World  regards  three  or  four  years  of 
extra  study  a  small  matter,  compared  with  the  lives  and  welfare  of 
the  community ;  the  New  World  considers  any  risk  preferable  to 
such  delay  in  entering  upon  the  practical  duties  of  life. 

The  Therapeutics  of  dentistry,  unlike  its  anatomy,  physiology 
and  pathology,  differs  from  that  taught  in  the  medical  schools. 
It  is  Medical,  Surgical  and  Prosthetic.  In  so  far  as  it  is  a  direc- 
tion of  medical  science  to  the  prevention,  modification  or  removal, 
by  medicinal  and  hygienic  remedies,  of  the  causes  and  effects  of 
disease  in  the  dental  organs,  it  forms  part  of  a  physician's  practice, 
just  as  does  the  treatment  of  cerebral,  cardiac,  or  pulmonary  dis- 
ease. In  so  far  as  it  is  an  application  of  surgical  skill  to  the 
extraction  of  teeth,  the  removal  of  tumors,  to  the  treatment  of 
fractures  or  to  staphyloraphy,  it  is  simply  Oral  surgery,  involving 
only  such  knowledge  and  skill  in  the  use  of  instruments  as  every 
surgeon  must  possess.  But  dental  therapeutics  includes  a  class  of 
operations  not  taught  in  medical  schools  and  not  practiced  in  the  . 
offices  of  physicians  or  surgeons ;  which,  for  their  successful  per- 
formance, require  surroundings  and  appliances  such  as  no  other 
class  of  operations  call  for;  demanding  also  an  amount  of  time 
and  special  experience  which  it  is  impossible  for  the  general  sur- 
geon to  devote  to  any  one  part  of  the  body.  Hence,  by  universal 
consent,  this  branch  of  therapeutics,  under  the  name  of  Dental 
Surgery,  is  assigned  to  a  special  class  of  practitioners,  who,  like 
the  oculist  and  obstetrician,  perfect  their  art  by  limiting  the  sphere 
of  its  duties. 

The  prevailing  and  distinguishing  feature  of  dental  therapeutics 
is  Prosthetics — the  art  of  replacement ;  replacement  of  dental  struc- 
ture, in  such  manner  and  with  such  material  as  shall  prevent  further 
action  of  the  destructive  agencies;  replacement  of  dental  organs, 
by  substitutes  which  shall  physiologically  restore  impairment  of 
function  and  aesthetically  restore  the  natural  expression  of  the  face. 
The  medical  therapeutics  aud  oral  surgery  of  dentistry  are  insuffi- 
cient to  establish  it  as  a  distinct  branch  of  medical  art;  whilst 
the  operations  of  filing  and  regulating  the  teeth  form  a  small  pro- 
portion of  its  specific  duties.  It  owes  its  extent  to  the  universal 
liability  of  the  teeth  to  decay  aud  loss;  it  owes  its  difficulty,  as  an 
art,  to  the  complex  nature  of  the  methods  by  which  this  loss  and 
decay  must  be  remedied.     In  other  words  Prosthetic  Mechanism 


INTRODUCTION.  XXXV 

constitutes  by  far  the  largest  and  most  difficult  part  of  dentistry, 
makes  it  a  distinct  branch  of  the  art  of  medicine,  and  gives  to  it 
the  power  to  add  as  it  does  to  health,  comfort,  and  the  enjoyment 
of  life. 

The  physician,  surgeon  and  dentist  have  necessarily  many  practi- 
cal duties  in  common;  but  each  has  a  clearly  defined  limitation  of 
sphere,  requiring  specific  direction  of  that  general  culture  which 
all  must  possess.  The  Physician  is  a  specialist ;  for,  although  he 
treats  diseases  which  affect  more  or  less  the  entire  body,  his  thera- 
peutics is  restricted  to  hygiene  and  the  materia  medica,  and  there 
are  many  accidents,  defects  and  pathological  conditions,  which  are 
beyond  the  reach  of  his  skill.  Moreover,  the  physician's  specialty 
tends  constantly  to  subdivision ;  nor  do  we  look  for  the  most 
valuable  contributions  to  medical  science,  except  from  those  who 
apply  themselves  exclusively  to  some  one  class  of  diseases.  Few 
minds  can  even  approach  that  universality  of  genius  which  char- 
acterized Hippocrates  and  John  Hunter;  hence  devotion  to  a 
specialty  of  medical  art  detracts  nothing  from  the  position  which 
a  man's  education  and  talent  entitle  him  to  assume. 

The  Surgeon  is  a  specialist,  although  few  confine  themselves  to 
a  practice  purely  surgical,  except  in  cities  and  hospitals.  Richer- 
and  correctly  defined  the  specialism  of  surgical  therapeutics  as  the 
"  quod  in  therapeia  mechanieum  ;^'  its  well-known  etymology  con- 
veys the  same  idea.  Yet  the  element  of  mechanism  and  necessity 
for  the  exercise  of  "hand-craft"  enter,  more  or  less,  into  all 
physical  sciences.  Astronomy,  chemistry,  pharmacy,  microscopic 
analysis  and  modern  medical  diagnosis  demand  extreme  accuracy 
of  manipulation;  and  all  great  discoverers  in  these  sciences  dis- 
play the  ability,  not  only  to  use,  but  also  to  invent  and  construct 
apparatus.  The  universal  recognition  of  the  great  value  of  this 
element  in  every  department  of  Physics  has  given  the  scientific 
world  a  more  correct  idea  of  the  true  dignity  of  highly-educated 
mechanical  skill — skill,  without  which  the  physician's  art  is  crip- 
pled, surgery  becomes  impotent  and  dentistry  has  no  existence. 

The  two  departments  of  dental  prosthetics.  Structural  and  Or- 
ganic, are  usually  classified  as  Operative  and  Mechanical  dentistry. 
We  have  given  preference,  in  this  work,  to  the  terms  dental  Sur- 
gery and  dental  Mechanics.  Another  classification  is  dentistry  of 
the  Chair  and  dentistry  of  the  Laboratory.  Each  of  these  three 
classifications  indicate  prevailing  characteristics,  but  all  fail  to  point 


XXXvi  INTRODUCTION. 

out  the  true  basis  both  of  the  unity  and  the  diversity  of  the  two 
branches  of  dental  practice.  The  editor  does  not  feel  at  liberty  to 
deviate,  in  the  present  volume,  so  widely  from  the  author's  arrange- 
ment ;  yet  he  may  here  suggest  the  following  classification  of  dental 
therapeutics,  or  the  Art  of  Dentistry.  I.  Medical.  II.  Surgical : 
(1.  Oral  surgery;  2.  Dental  surgery.)  III.  Prosthetic:  (1.  Struc- 
tural ;  2.  Organic.) 

As  medicine  and  surgery  are  combined  in  the  practice  of  the 
majority  of  medical  men,  so  the  two  classes  of  prosthetic  mechan- 
ism are  usually  practiced  together;  but  such  practice,  although  in 
a  laro-e  number  of  cases  unavoidable,  does  not  tend  to  the  develop- 
ment of  highest  excellence  in  either  department.  Certain  details 
of  the  laboratory  unfit  the  hand  for  some  of  the  more  delicate 
operations  of  structural  prosthetics;  whilst  the  engrossing  and 
more  remunerative  duties  of  the  chair  almost  inevitably  lead  to  a 
hastv  and  negligent  performance  of  laboratory  work.  The  usual 
method  of  meeting  this  difficulty,  that  is  by  dividing  the  duties  of 
orc^anic  prosthesis,  cannot  be  too  severely  condemned.  It  is  like 
requiring  an  artist  to  paint  a  correct  portrait  from  verbal  descrip- 
tion •  it  io-nores  every  principle  of  dental  aesthetics,  and  its  results 
are  artificial  dentures,  so  devoid  of  expression  and  individuality,  as 
to  mar  the  features  they  are  intended  to  adorn.  But  the  prosthetic 
character  of  dentistry  subjects  it  to  a  danger  more  serious  than  this 
unwise  division  of  inseparable  duties. 

Scientific  mechanism  implies  not  only  skill  in  construction,  but 
judgment  and  purpose  in  application.  Unfortunately  a  few  months' 
use  of  tools  enables  one  who  has  natural  aptitude  in  handling  them 
to  produce  specimens  of  workmanship  which  are  accepted  as  evi- 
dence of  peculiar  fitness  for  dentistry.  If  no  early  education  has 
onven  habits  of  study,  the  fascinations  of  hand-work  are  permitted 
to  engross  time  that  should  be  given  to  the  harder  and  more  dis- 
tasteful head-work.  The  training,  thus  commencing  and  ending  in 
mechanism,  is  discreditable,  not  because  of  its  mechanism,  but 
because  being  one-sided  and  partial,  it  necessarily  fails  to  accomplish 
that  which  it  promises.  Such  training  may  make  dental  laborers, 
tradesmen,  or  artisans ;  but  never  dental  artists,  or  scientific  me- 
chanicians :  nor  can  the  dentistry  which  they  practice  be,  in  any 
respect,  identified  with  that  which  we  have  defined  as  a  branch  of 
the  art  of  medicine. 

A  preparation  begun  in  pure  science  may  end  in  correct  practice, 


INTRODUCTION.  XXXVU 

and   the  early  habits   of  student-life  may  follow  the  professional 
man  throughout   his  career;  but  a  preparation  begun  in  practice 
will  end  there.     The  routine  of  professional  duties  often  tempt  the 
scholar  to  sink  into  the  mere  practitioner ;  it  is  rare  indeed  that 
one  reverses  the  order  of  nature  and  sets  aside  the  claims  and  emolu- 
ments of  practice,  to  acquire  slowly  those  habits  of  study  so  easily 
learned  in  youth.     It  requires  the  broadest  literary  and  classical 
education   of    boyhood   to   counteract   the  necessarily   narrowing 
influence  of  the  professional  studies  of  manhood  ;  and  it  demands 
the  largest  possible  infusion   of  purely  scientific  teaching,  during 
professional    pupilage,    to   correct    the  matter-of-fact    influence  of 
practice.     In  this  lies  the  great  error  of  American  practical  systems 
of  education.     They  teach  boyhood  to   take  a   utilitarian  view  of 
every  lesson  learned,  and  encourage  young  men  to  neglect  studies 
in  which  they  cannot  see  some  prospective  pecuniary  value.     It  is 
the  application  to  science  and  art  of  that  philosophy  of  life  which 
subordinates  mind  and  body  to   the  one  idea  of   making  a  living; 
that  spirit  of  trade,  which  regards  classical  study  a  waste  of  the 
years  in  which  plastic  youth  can  best  be  moulded  into  the   mer- 
cantile idea  of  Profit  and  Loss.     Limitation,  first  in  the  amount 
of  mental  culture,  secondly  in  its  direction,  is  thus  made  to  combine 
with  the  inevitable  influence  of  all  exclusive  pursuit,  whether  of 
science  or  business;  the  result  is  a  rapid  increase,  in  all  professions, 
of  men  whose  vision  is   limited  by  the  narrow  horizon  of  their 
special  occupation,  and  who  possess  none  of  that  large-minded  lib- 
erality which  is  the  outgrowth  of  a  generous  education.     It  is  by 
such    early  restriction   of   thought  and  action  within    the  narrow 
grooves  of  life's  future  pursuits  that  a  merchant  so  often  loses  all 
power  to  enjoy  the  fruit  of  his  toil,  a  physician  is  unknown  beyond 
the  sick-room,  a  surgeon  contributes  nothing  to  the  cause  of  science, 
and  a  dentist  holds  no  social  position.     This  inevitable  tendency  of 
purely  practical  education  was  recognized  by  Lord  Brougham  when 
he  recommended  Dante,  as  a  text-book,  to  an  inquiring  student 
of  law. 

The  antagonism  of  trade  and  pure  science  is  seen  not  only  in  the 
result  of  attempting  to  make  all  education  utilitarian.  It  appears, 
whenever,  in  professional  life,  the  laws  of  barter  come  to  be  applied 
to  brain-work  and  its  products.  Mercantile  relations  of  cost  and 
price  are  capable  of  definite  adjustment,  when  applied  to  commodi- 
ties of  known  values,  enhanced  by  labor  at  given  rates;  there  are 


XXXVlll  INTRODUCTION. 

data  also  upon  which  the  speculative  fluctuations  of  prospective 
supply  and  demand  are  based  :  so  that  in  all  bargains,  buyer  and 
seller  may  stand  upon  the  ground  of  equal  ability  to  judge  these 
questions.  But  professional  service  is  amenable  to  no  such  standard : 
the  client  cannot  estimate  the  cost  of  his  lawyer's  pleading,  nor  can 
the  patient  know,  until  long  afterwards,  the  full  value  of  his  phy- 
sician's prescription.  The  conditions  of  honest  barter  are  absent, 
for  client  and  patient  are  alike  dependent  upon  the  integrity  of  the 
professional  man  ;  hence  professional  bargaining  is  dishonorable, 
and  inevitably  leads  to  the  rendering  of  a  disreputable  grade  of 
service.  The  common  practice  of  v^aluation  by  the  visit  or  the  hour 
is  so  manifestly  unequal  in  its  working,  that  it  is  only  another  proof 
of  the  impracticability  of  measuring  science  and  art  work  by  com- 
mercial standards. 

The  medical  fee  is  a  valuation  of  thought  and  skill,  exercised 
for  the  preservation  of  life  and  health.  On  the  part  of  the  patient, 
it  is  considered  a  gratuity,  by  those  who  fail  to  perceive  the  elements 
of  cost  in  such  a  work  ;  a  compensation,  by  those  who  recognize  an 
equivalent  received ;  au  acknowledgment,  by  the  few  who  refuse  to 
believe  that  money  can  adequately  reward  such  service.  Viewed 
from  the  professional  side,  the  fee  has  nothing  to  do  with  the  quality 
of  the  service,  nor  does  it  enter  into  the  mind  of  any  right-thinking 
man,  whilst  rendering  it.  Mr.  Ruskin  says,  with  great  truth,  "it 
is  impossible  for  a  well-educated,  intellectual  or  brave  man  to  make 
money  the  chief  object  of  his  thoughts;  yet  a  healthy-minded  man 
enjoys  the  honest  winning  of  money,  and  will  insist  upon  a  fair 
valuation  of  his  work.  But  with  all  brave  men,  the  work  is  first, 
and  the  fee  second ;  whilst  there  is  a  vast  class,  ill  educated, 
cowardly,  and  more  or  less  stupid,  with  whom  the  fee  is  first  and 
the  work  second." 

All  professions  have  suffered  much  by  this  perverted  application 
of  mercantile  law  to  professional  fees;  but  none  so  severely  as 
dentistry.  This  is  due  to  the  prevalent  idea,  that  the  gold  filling 
and  the  artificial  denture  are  as  legitimate  objects  of  barter  and  eon- 
tract  as  any  other  tangible  article  of  manufacture :  whereas,  in 
reality,  they  are  no  more  so  than  the  surgical  operation,  or  the 
medical  advice.  When  the  dentist  forsakes  the  vantage  ground  of 
a  professional  fee  for  "services  rendered,"  and  condescends  to 
bargain  for  the  definite  products  of  his  skill,  he  at  once  destroys  the 
professional  character  of  his  position.     Not  only  does  he  lose  caste ; 


INTRODUCTION.  XXxix 

but  in  the  class  to  wliich  he  has  descended,  the  question  of  price 
invariably  leads  to  considerations  of  cost,  and  the  quality  of  his 
work,  slowly  perhaps,  but  surely,  deteriorates.  The  disastrous 
influence  of  vulcanite  abundantly  proves  that,  when  cost  of  material 
is  permitted  to  enter  as  an  element  in  determining  the  value  of 
scientific  art-work,  it  inevitably  degrades  it;  and  the  entire  history 
of  prosthetic  dentistry  shows  that  competition  in  price  (the  develop- 
ment of  Mr.  Buskin's  "  fee  first  and  work  second  ")  is  fatal  to  all 
progress  in  art  or  advancement  in  science.  The  results  of  such  com- 
petition are,  to  honest  men,  a  life  of  slavish  toil,  with  no  time  for 
self-improvement;  to  others,  a  deliberate  slighting  of  work  which 
destroys  all  the  nobility  of  a  man's  nature.  Dentistry,  thus  learned 
and  thus  practiced,  has  no  just  claim  to  be  called  a  profession;  it 
has  neither  the  liberality,  generosity,  nor  culture,  which  men  are 
accustomed  to  associate  with  professional  life ;  and  its  pretentious 
claims  serve  only  to  call  to  mind  the  satire  of  Juvenal,  "  Scire 
volunt  omnes,  mercedem  solvere  nemo." 

Dentistry,  as  a  true  science  and  art,  is  built  upon  the  foundation 
of  a  generous  early  education,  is  enlightened  by  a  complete  medical 
course  of  instruction,  is  specially  trained  by  a  full  term  of  practical 
pupilage,  and  recognizes  no  sliding-scale  in  the  quality  of  the  service 
it  renders.  Such  dentistry  will  exercise  influence  in  its  own,  and 
command' respect  among  kindred  professions;  for  it  becomes  thus 
a  curative  work,  second  in  importance  and  extent  of  its  usefulness 
to  no  specialty  of  the  great  Art  of  Healing. 


Fig.  /.     Fig.  : 


Pig.  3. 


Toungest  layer 

Production  of  formed  material  from  -. 
ooveriug  papilla  of  the  tougue.     x: 


Jng-I^ 


Fig.  S. 


Fig.  «. 


Middle  layer.  >     ^^     OhK 

■n  Epithelial  cells,  from  sect  on  tliroa;'i  layer  oriipiiheliun 


/    ;. 


■/ 


/"■V/-'^ 


-"   ? 


FORMATION  OF  PUS. 

To  illustrate  the  change  in  (-'crrainal  matt'»  of  an  Eoithelial  cell,  resulting  from  increased  nntrition,  showing  the 

manner  in  wliich  the  (jeriuiuai  muiUM'  ct  a  normal  cell,  if  supplied  li-eelv  with  pabulum,  may  jive  rise  to  pus. 

Fig.  U. 


Fig.  13. 


■I     |f||fli|| 


aa       > 


Young.       Fully  formed  Young.  j-  uuy  i 

TENDON.  CARTILAGE. 

Fig.  ii. 


Fig.  IB. 


ELASTIC  TISSUE. 
The  arrow  shows  the  direction  in  which  germinal 
matter  is  supposed  Ui  be  zuoviug 


Development  of  young,  dark-bordered  nerve  fibres,  at  an  early 
period,  showing  permiiial  inauor  and  formed  material  of 
elementary  parts.     X 1800. 


New  centre  or  nucleolu 


Oldest  part  of  formed 
^       material. 


i^ermiiuii  joMtor  .nucleusj. 


Pore  X5000. 


Course  of  pabu ;  i:  ly.    * 


PLATE  ILLUSTKATING  DR.  BEALE'S  VIEWS. 

From   Tyson'.s  Cell  Doctrine. 


THE 


PRINCIPLES   AND   PRACTICE 


DENTISTRY. 


CHAPTER  I. 

DEVELOPMENT    OF   THE    CELL   DOCTRINE. 

THE  point  of  departure  in  the  study  of  anatomy  and  physiology,  of 
all  the  phenomena  of  life,  indeed,  is  the  cell ;  and  so  general  is 
the  attention  now  directed  to  this  point  of  investigation  by  scientific 
and  learned  men  of  all  classes,  that  no  work  professing  to  treat  of 
physiology  can  be  considered  complete  that  does  not,  at  least,  give  an 
epitome  of  the  most  popular  views  on  the  subject  of  cell  constitution 
and  cell  growth.  Before  directing  attention  to  that  theory  which,  in 
the  opinion  of  the  writer,  seems  most  worthy  of  acceptance,  we  propose, 
therefore,  to  give  a  very  brief  exposition  of  the  state  of  scientific  in- 
formation on  this  subject,  together  with  a  statement  of  those  investiga- 
tions that  have  finally  culminated  in  the  present  accepted  views  ;  and 
then,  with  as  much  brevity  as  is  compatible  with  clearness,  state  that 
doctrine  which  seems  to  embody  most  of  truth,  without  pausing  to 
consider  the  objections  that  may  have  been  brought  against  it.  In 
1679,  Malpighi  recognized  the  blood  corpuscles,  and  elaborately  in- 
vestigated the  cell  structure  of  plants,  to  which  Robert  Hook  had 
called  attention,  1667.  He  showed  that  the  "cells,"  or  "vesicles," 
were  separable ;  that  each  "  cell  "  was  an  independent  entity,  to  which 
he  gave  the  name  "utriculus."  In  1687,  the  blood  corpuscles  were 
well  described  by  Leuwenhoeck,  who  also  discovered  the  spermatozoids, 
which  he  believed  to  be  sperm  animals  of  distinct  sexes.  Haller  was, 
however,  the  first  to  attempt  to  construct  the  tissues  by  the  association 

41 


42  PEINCIPLES   AND   PRACTICE   OF  DENTISTRY. 

of  their  ultimate  anatomical  elements.     His  elements  were  the  "  fibre  " 
and  an  "organized  concrete,"  the  office  of  the  latter  being  simply  to 
bind   the   fibres   together   as   a  glue.     Wolf,  in   1759,  advanced  the 
theory  that  in  a  clear,  viscous  fluid,  without  organization  of  any  kind, 
cavities  were  developed,  which,  if  rounded  or  polygonal,  became  cells ; 
if  elongated,  vessels ;  and  that  the  law  was  the  same  for  both  plants 
and  animals,  except  that  in  the  plants  the  cells  were  finally  separated 
from  each  other,  while  "  in  the  animals  they  always  remained  in  com- 
munication.    In  each  case  they  are  mere  cavities,  and  not  independent 
entities;  organization  is  not  effected  by  them,  but  they  are  the  visible  re- 
sults of  the  organizing  power  inherent  in  the  living  mass,  or  what   Wolf 
calls   the  vis  essentialis."  *     Haller's  doctrine  continued,  however,  to 
maintain  ascendancy  until  near  the  close  of  the  eighteenth  century, 
when  it  gave  place  to  the  "globular  "  theory,  originally  advanced  by 
Leuwenhoeck  in  1687,  but  which  had  attracted  little  attention  at  that 
time.     Near  the  close  of  the  eighteenth  century,  quite  a  formidable 
array  of  great  names  are  associated  with  it.     The  term  "globule," 
understood  by  most  writers  of  this  day  to  mean  a  spherical  body,  with 
a  dai^k  outline  and  a  bright  centre,  was  then  used  indiscriminately  with 
granule  and  molecule,  which  are  commonly  now  held  to  be  bodies  of 
indeterminate  shape,  though  Virchow  and  other  German  writers  some- 
times use  them  as  convertible  terms.     "  Prochaska,  in  1779,  described 
the  brain  as  made  up  of  globules  eight  times. smaller  than  blood  glob- 
ules.    In  the  year  1801,  the  philosophic  mind  of  Bichat  elaborated  his 
excellent  classification  ;  but  he  seems  to  have  made  no  original  investi- 
gations in  minute  structure,  or  to  have  adopted  any  special  theory  of 
an   ultimate   physical   element.     The   brothers   Joseph   and   Charles 
Wenzel,  in  1812,  described  the  brain  as  composed  of  globules  of  small 
size.     Among  the  earliest  histologists  worthy  of  mention  is  Treviranus, 
whose  elements,  according  to  Henle,  were  first,  a  homogeneous  form- 
less matter  ;  second,  fibres  ;  third,  globules  (Kiigelchen).     Mr.  Bauer, 
quoted  as  a  most  experienced  microscopic  observer  by  Sir  Everard 
Home,  in  1818,  and  again  in  1823,  describes  the  ultimate  globules  of 
the  brain,  and  of  muscular  fibre,  as  of  the  size  of  a  globule  of  blood 
deprived  of  its  coloring  matter,  or  about  ^-^o  of  an  inch  in  diameter. 
The  fibre  was  excluded  as  an  ultimate   element  of  organization  by 
Heusinger  in   1822-4,  who  started  all  tissues  from  the  globule,  still, 
however,  retaining  the  formless  material  of  Haller  and  Treviranus. 
Heusinger  formed  the  fibre  by  the  linear  apposition  of  the  globular 
elementary  parts,  and  even  explained  how  canals  and  vessels  were 
formed   by  a  similar  arrangement  of  vesicles  which  had   originated 
from  the  globules."  f     Milne  Edwards  must  be  credited  more  than 
*  Huxley,  as  quoted  in  Tyson's  Cell  Doctrine,     f  Tyson's  Cell  Doctrine,  23. 


DEVELOPMENT    OF    TPIE    CELL    DOCTRINE.  43 

any  other  writer  with  the  establishment  of  the  gh)l)uhir  doctrine.  He 
held  that  all  tissues,  both  animal  and  vegetable,  were  formed  by  the 
aggregation  of  globules.  Baumgiirtner  and  Arnold,  in  1830-38,  held 
a  similar  doctrine.  Dr.  Hodgkin,  of  London,  in  1829,  showed  the 
fallacy  of  Edwards'  view,  and  the  globular  theory  began  to  lose 
ground  except  in  the  more  limited  sense  of  "granule."  Dr.  Robert 
Brown,  in  1833,  discovered  the  nucleus,  though  he  seems  not  to  have 
appreciated  its  importance.  Raspail,  in  1837,  tells  us  that  develop- 
ment takes  place  from  "  cells  "  or  vesicles,  capable  of  indefinite  multi- 
plication, endowed  with  life,  and  capable  of  absorbing  oxygen,  and  of 
spherical  form  ;  that  the  cell  is  made  up  of  atojns  crystallizing  about 
an  ideal  centre,  the  cell  being  represented  by  the  crystal  rather  than 
the  atoms  of  which  it  is  composed.  Dutrochet  held  that  the  solids  and 
fluids  of  the  body  were  alike  composed  of  cells  ;  that  in  the  solids  they 
were  more  closely  attached,  while  in  the  liquids  they  moved  freely, 
while  other  structures,  also  composed  of  cells,  were  difficult  to  refer  either 
to  the  solids  or  liquids.  Animal  fibres  he  considered  made  up  of 
elongated  cells,  and  that  vegetable  structures  were  formed  on  the  same 
general  plan.  After  the  discovery  of  the  nucleus  by  Dr.  Robert 
Brown,  it  was  observed  by  quite  a  number  of  investigators,  among 
whom  were  Valentin,  Purkinje,  Turpin,  Schultze,  Rudolph,  Wagner, 
and  Henle,  most  of  whom  had  observed  the  development  of  cells 
about  a  pre-existing  nucleus  ;  and  Valentin  had  traced  in  the  nucleus  of 
epidermic  cells  a  resemblance  to  the  nucleus  of  vegetable  cells,  and 
had  shown  in  the  crystalline  lens,  and  in  muscular  fibre,  the  develop- 
ment of  fibres  from  cells,  while  Quatrefages  and  Dumourier  had  ob- 
served the  origin  of  young  cells  from  old  in  the  embryo  of  the  snail, 
all  before  the  appearance  of  Schleiden's  work.  To  Schleiden  is  due 
the  credit  of  first  establishing  (1838)  a  uniform  system  of  cell  de- 
velopment in  vegetable  structures,  of  which  the  cell  was  the  unit,  and 
to  Schwann  the  extension  of  the  theory  to  animal  structures.  To  the 
nucleus  Schleiden  gives  the  name  "cytoblast,"  or  cell  germ.  He  also 
calls  attention  to  the  neucleolus,  which  he  thinks  is  formed  before  the 
cytoblast.  "  The  entire  growth  of  the  plant,"  says  he,  "  consists  only 
of  the  formation  of  cells  within  cells."  Schwann  applied  Schleiden's 
theory  of  vegetable  growth  to  animal  tissues.  The  nucleolus  is  first 
fornjed  in  a  granular  or  structureless  cytoblastema,  and  around  it  is 
deposited  a  substance,  granular  or  structureless,  in  which  new  molecules 
are  deposited  between  those  already  formed  around  about  the  nu- 
cleolus, thus  forming  the  nucleus.  When  this  deposition  "goes  on 
equally  throughout  the  entire  thickness  of  the  stratum,  the  nucleus 
may  remain  solid ;  but  if  it  goes  on  more  vigorously  in  the  external 
part,  the  latter  will  become  more  dense,  and  may  become  hardened 


44  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

into  a  membrane,  and  such  are  the  hollow  nuclei."  *  After  reaching 
a  certain  stage,  there  is  deposited  about  the  nucleus  a  stratum  of  sub- 
stance, differing  from  the  cytoblastema,  by  which  the  complete  cell  is 
formed.  This  substance  may  be  either  homogeneous  or  granular,  more 
frequently  the  latter.  At  first  the  cell  wall  and  cell  cavity  cannot  be 
distinguished  from  each  other ;  but  as  the  deposition  continues,  the 
cell  wall  becomes  denser  and  more  clearly  defined,  until  the  external 
layer,  when  the  stratum  is  thick,  or  the  entire  stratum,  when  it  is  thin, 
becomes  consolidated  into  a  membrane,  while  many  cells  that  seem  to 
be  continuously  solid  present  only  a  little  greater  density  on  the 
surface.  After  the  formation  of  the  membrane  it  continues  to  grow  by 
the  continued  deposition  of  new  molecules  between  the  preexisting 
ones,  becoming,  at  the  same  time,  separated  from  the  nucleus  ;  the 
space  thus  left  subsequently  becomes  filled  with  fluid.  Thus,  Schleidea 
and  Schwann  seem  to  have  anticipated  most  of  what  is  now  known 
in  reference  to  tissue  formation  from  cells,  while  differing  considerably 
from  present  theories  concerning  the  growth  of  the  cell  itself,  and 
the  situation  of  its  nucleus,  which  they  placed  near  the  cell  wall,  while 
most  writers  of  the  present  day  place  it  centrally,  though  not  uniformly 
so  ;  nor  do  more  recent  writers  hold  that  either  the  cell  wall  or  nucleus 
is  essential  to  the  ultimate  anatomical  element,  as  was  held  by  them. 
Henle,  in  1841,  recognized  three  modes  of  cell  formation — budding, 
endogeneous  growth,  and  segmentation — which  latter  had  been  denied 
by  Schleiden  and  Schwann  ;  nor  did  he  seem  to  recognize  the  nucleus 
as  an  essential  part  of  the  cell.  Richart,  in  1840,  failed  to  find  it 
uniformly  present.  Karsten,  in  1843,  stated  "  that  cells  originate 
without  a  pre-existing  nucleus,  and  by  the  expansion  of  amorphous 
granules  of  organic  matter."  Kolliker,  in  1844,  dissented  from  the 
idea  of  a  single  method  of  cell  formation,  and  Mr.  Paget,  in  1846, 
"  declared  that  cells  might  arise  in  some  other  way  than  from  a 
nucleus."  In  1841,  Dr.  Martin  Barry  writes,f  "I  am  very  much  in- 
clined to  believe  that  in  the  many  instances  in  which  authors  on  '  cells 
have  described  and  figured  more  than  one  nucleolus  in  a  nucleus,  there 
has  been  either  an  apparent  division  of  the  nucleus  into  discs,  or  the 
nucleus  has  consisted  of  two  or  more  discs  ;  the  nucleoli  of  those  authors 
have  been  the  minute  and  highly  refracting  cavities  or  depressions  in  the 
discs.  If  this  has  really  been  the  case,  it  afibrds  additional  evidence,  I 
think,  that  reproduction  of  cells  by  the  process  I  have  described,  nmnely, 
division  of  the  nucleus  of  the  present  cell,  is  universal,  so  numerous  have 
been  the  instances  in  question.'  .  .  ,  The  nuclei  which  various  ob- 
servers have  found  lying  among  the  fibres  of  various  tissues,  have 

*  Schwann,  as  quoted  by  Tyson,  p.  43. 

t  Philosophical  Transactions  for  1841,  pp.  207,  208. 


DEVELOPMENT    OF   THE    CEEL    DOCTRINE.  45 

been  considered  by  them  as  the  '  remains  of  cells.'     This  may  have 
been  the  case  ;  but  so  far  from  thinking,  with  those  observers,  that  the 
nuclei  in  question  were  '  destined  to  be  absorbed,'  I  am  disposed  to 
consider  that  they  are   sources   from   which  would  have  arisen  new 
cells."     In  1845,  Prof.  John  Goodsir  published  a  paper  on  "Centres 
of  Nutrition,"  in  which  is  embodied  the  two  most  important  facts  in 
the  cell  doctrine  of  the  day,  viz.— the  activity  of  these  centres  (nuclei), 
the  manner  in  which  they  derive  nutriment  from  the  capillaries  or 
other  sources,  distributing  it  "by  development  to  each  organ  or  tex- 
ture after  its  kind,"  and  the  development  of  all  such  centres  from  pre- 
existing centres  or  nuclei.*     "As  the  entire  organism  is  formed  at 
first,  not  by  simultaneous  formation  of  its  parts,  but  by  the  successive 
develoynent  of  these  from  one  centre,  so  the  various  parts  arise  each 
from  its  own  centre,  this  being  the  original  source  of  all  the  centres 
with  which  the  part  is  ultimately  supplied."     Thus,  not  only  does  the 
whole  organism  consist  of  "  simple  or  developed  cells,"  with  an  inde- 
pendent vitality,  "but  that  there  is,  in  addition,  a  division  of  the  whole 
into  departments,  each  containing  a  certain  number  of  developed  cells, 
all  of  which  hold  certain  relations  to  one  central  or  capital  cell,  around 
which  they  are  grouped.     It  would  appear  that  from  this  central  cell 
all  the  other  cells  of  its  department  derive  their  origin.     It  is  the 
mother  of  all  those  within  its  own  territory."     He  divides  these  centres 
of  nutrition  into  two  kinds— those  that  are  "  peculiar  to  the  textures, 
and  those  that  belong  to  the  organs."     The  former  are  generally  perma- 
nent, while  the  latter  last  only  during  embrj^onic  life,  and  finally  dis- 
appear, 01'  "  break  in  the  various  centres  of  the  textures  of  which  the 
organ  is  composed."     "J.  mdritive  centre,  anatomicallij  considered,  is 
merely  a  cell,  the  nucleus  of  which  is  the  permanent  source  of  successive 
broods  of  young  cells."     Prof.  Huxley  taught,  in    185>!,  that  vitality 
was  "  a  property  inherent  in  certain  kinds  of  matter,"  and  that  there 
is  a  condition  of  all  kinds  of  living  matter  in  which  it  is  simply  an 
amorphous  germ,  possessing  no  structure,  its  external  form  depending 
exclusively  on  physical  laws,  and  that  the  successive  differentiations 
or  changes  of  this  amorphous  mass  will  depend  on  previously  existing 
conditions.     This  differentiation  may  be  of  two  kinds :  in  "  unicellular 
organisms"  it  is"  e.T^er?ia/;"  that  is,  is  concerned  only  in  the  shape 
of  the  organism,  without  reference  to  any  internal  structure ;  but  in 
all  higher  organisms  the  external  difierentiation  is  preceded  or  accom- 
panied by  an  internal  change,  and  the  "  homogeneous  germ  "  is  con- 
verted into  a  central  portion  or  endoplast  and  a  peripheral  or  periplast, 
thus  constituting  the  germ  a  vesicle  with  a  nucleated  centre.     He  said 
there  was  "no  evidence  whatever"  that  the  vital  forces  were  resident 

*  Tyson,  p.  46. 


46  PRINCIPLES   AND    PRACTICE   OF    DENTISTRY. 

exclusively  in  either  the  endoplast  or  the  periplast,  or  that  they  exerted 
any  attraction  over  each  other  ;  that  though  they  were  in  harmony,  the 
changes  which  they  subsequently  underwent  had  no  "  causal  con- 
nection." That  the  endoplast,  so  far  from  being  the  seat  of  especial 
vital  action,  underwent  no  morphological  change  whatever,  except 
growth  and  division,  while  the  periplast  was  the  subject  of  the  most 
important  metamorphic  changes,  morphological  and  chemical ;  by  its 
differentiation  all  the  various  tissues  are  produced  through  molecular 
changes  in  its  structure,  under  the  guidance  of  the  vital  force.  This 
metamorphosis  of  the  periplast  is  of  two  kinds,  "  chemical  and  struc- 
tural,"— the  former  may  consist  in  "conversion,"  as  of  cellulose  into 
xylogen,  etc.,  or  in  "  deposit,"  as  of  earthy  matter  in  the  bone  of  ani- 
mals, and  in  plants.  ^ 

The  peculiarities  of  Prof  Huxley's  doctrine  at  that  time  were  the 
substitution  of  the  term  ^'endoplast"  for  "nucleus,"  "periplast"  for 
"  cell  ivall;"  the  perfectly  passive  nature  of  the  "  endoplast,"  as  well  as 
of  the  periplast,  so  far  as  the  determination  of  change  was  concerned, 
though  itself  the  seat  of  very  active  change.  He  also  held  that  the 
"  vital  phenomena  are  not  necessarily  preceded  by  organization,  nor 
are  in  any  way  the  result  or  effect  of  formed  parts,  but  that  the 
faculty  of  manifesting  them  resides  in  the  matter  of  which  living  bodies 
are  composed  as  such  ;  or,  to  use  the  language  of  the  day,  that  the  vital 
forces  are  molecular  forces."  He  also  denied  the  invariable  presence 
of  the  nucleus,  and  believed  that  all  cell  development  occurred  by 
division,  except  in  some  vegetable  organisms  which  he  specified. 

Dr.  J.  Hughes  Bennett  also  held  that  the  "ultimate  parts  of  organi- 
zation "  were  not "  cells  "  or  "  nuclei,"  but  the  "  molecules  "  of  which  they 
were  formed  ;  and  that  these  molecules,  by  virtue  of  some  "  independent 
physical  and  vital  property,"  were  enabled  to  unite  so  as  to  form  the 
various  tissues.  To  these  molecules  he  gives  the  names  "  histogenetic," 
or  "  tissue-forming,"  and  "  histolytic,"  or  disintegrative.  With  him  the 
first  step  in  organization  is  the  formation  of  an  "  organic  fluid,"  and 
the  precipitation  therefrom  of  "organic  molecules,"  from  which,  ac- 
cording to  the  molecular  theory,  "  all  textures  are  derived."  He  is 
also  an  advocate  of  spontaneous  generation,  and  "  admits  the  produc- 
tion of  cells  by  buds,  division  or  proliferation,  without  a  new  act  of 
generation."  As  late  as  1856,  Messrs.  Todd  and  Bowman  are  found 
advocating  the  free-cell  formation  theory  of  Schleiden  and  Schwann. 
They  say,  taking  up  the  ovum  after  fecundation,  "  at  this  period  the 
embryo  consists  of  an  aggregate  of  cells,  and  its  further  growth  takes 
place  by  the  development  of  new  ones.  This  may  be  accomplished  in 
two  ways :  first,  by  the  development  of  new  cells  within  the  old,  through 
the  subdivision  of  the  nucleus  into  two  or  more  segments  and  the  forma- 


DEVELOPMENT   OF   THE    CELL    DOCTRINE.  47 

tion  of  a  cell  around  each,  which  then  becomes  the  nucleus  of  a  new 
cell,  and  may  in  its  turn  become  the  parent  of  other  nuclei;  and 
secondly,  by  the  formation  of  a  granular  deposit  between  the  cells,  in 
which  the  development  of  the  new  cells  takes  place.  The  granules 
cohere  to  each  other  in  separate  groups  here  and  there,  to  form  nuclei, 
and  around  each  of  these  a  delicate  membrane  is  formed,  which  is  the 
cell  membrane.  The  nuclei  have  been  named  eytoblasts,  because  they 
appear  to  form  the  cells ;  and  the  granular  deposit  in  which  these 
changes  take  place  is  called  cytoblastema.*  In  one  of  these  ways, 
accoi'ding  to  these  observers,  all  cells  are  formed ;  the  precise  manner 
in  which  the  tissues  are  formed  from  the  cells,  they  declare  themselves 
unable  to  state. 

The  probable  changes  which  occur  in  the  cell,  they  describe  under 
two  heads — those  that  take  place  in  the  cell  membrane  and  those  that 
take  place  in  the  nucleus.  In  all  real  or  apparent  fibrous  structures,  as 
"  areolar  and  fibrous  tissues,  the  cell  membrane  becomes  elongated," 
and  gives  the  appearance  of  being  divided  into  minute  fibres ;  in  the 
tissues  which  are  composed  of  homogeneous  tubes  filled  with  a  peculiar 
substance,  the  cells  become  attached  end  to  end,  the  partition  is 
absorbed,  and  the  tube  formed  in  which  is  deposited  the  proper  nerve 
or  muscular  substance.  The  capillaries  are  likewise  formed  by  the 
coalescence  of  the  cells  at  many  points  by  pointed  processes  which  are 
given  off  from  them.  Dr.  Carpenter  also  gives  in  detail  the  mode  of 
free  cell  development  as  "one  of  two  principal  modes"  in  which  cells 
"  may  originate,"  whilst  at  the  same  time  he  declares  himself  an  advo- 
cate of  the  views  entertained  by  Dr.  Lionel  Beale.  Prof.  Virchow,  on 
the  other  hand,  in  his  "  Cellular  Pathology,"  published  in  1858,  states 
that  cells  can  only  originate  from  pre-existing  cells,  and  describes  the 
typical  cell  as  consisting  of  "  cell  wall,"  "  cell  contents,"  nucleus,  and 
in  the  fully  developed  cell,  usually  a  "  nucleolus,"  though  it  is  not 
essential.  Later,  he  is  reported  as  holding f  "  that  a  nucleus  surrounded 
by  a  molecular  blastema  was  sufficient  to  constitute  a  cell;"  the  "  cell  wall" 
being  unessential.  The  cell  he  considers  the  centre  of  activity  beyond 
which  life  cannot  be  removed,  and  from  it  proceed  all  physiological  and 
pathological  processes,  and  though  each  cell  is  an  independent  centre  of 
vitality,  yet  as  they  are  necessarily  associated  in  the  construction  of  vari- 
ous tissues,  they  are  in  so  much  mutually  dependent ;  and  as  they  are 
severally  associated  for  the  attainment  of  particular  ends,  he  divides  them 
into  certain  districts  or  "  cell  territories,"  as  previously  taught  by  Good- 
sir,  the  intercellular  substance  deriving  peculiar  properties  from  its  par- 
ticular association.    On  the  nucleus,  according  to  this  writer,  depends  the 

*  Todd  and  Bowman,  Physiological  Anatomy,  p.  63,  Amer.  Edit.,  1857. 
t  Tyson's  Cell  Doctrine,  p.  6L 


48  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

life  of  the  cell,  while  to  the  cell  contents  over  and  above  the  nucleus 
belongs  the  function  of  the  structure,  neurility,  contractility,  secretion, 
for  nerve,  muscle  and  gland,  respectively.  Nor  does  he  believe  in  the 
so-called  effusions,  holding  rather  that  all  plastic  deposits  are  the  result 
of  excessive  cell  proliferation  of  the  tissue  concerned,  and  are  not  an  effu- 
sion from  the  blood,  as  is  thought  by  Beale ;  nor  does  he  except  even  fibrin 
found  external  to  the  blood  vessels.  Another  peculiarity  of  his  doctrine 
is — not  as  Schleiden  and  Schwann  taught,  and  as  is  generally  believed, 
that  all  tissues  healthy  or  morbid  result  from  the  apposition  of  cells — 
that  all  physiological  and  pathological  growths  result  from  a  imrticular 
cell,  the  cell  of  the  connective  tissue ;  from  it  are  formed  muscular  and 
nerve  fibres,  and  by  the  too  rapid  proliferation  of  these  cells  pus  is 
formed,  and  by  their  perverted  growth  tubercle,  cancer,  and  all  morbid 
growths  ;  though  he  admits  that  pus  may  also  be  formed  in  the  develop- 
ment of  epithelium,  either  of  mucous  membrane  or  cuticle;  and  lastly, 
he  supplements  the  lymphatic  and  capillary  systems  by  a  peculiar 
system  of  tubes  or  canals,  resulting  from  the  anastomosis  of  one  cell 
with  another,  which  he  classes  with  the  great  canalicular  system,  and 
to  it  refers  the  "  cord-like  fibres  of  yellow  elastic  tissue,"  which  he 
thinks  originate  in  the  connective  tissue  corpuscle.  Singularly  enough, 
after  stating  that  every  tissue  is  formed  from  cells,  he  says,  that  "  pure 
white  fibrous  tissue  does  not  have  its  origin  in  cells,  but  is  a  modifica- 
tion of  a  previously  homogeneous  intercellular  substance,  deposited 
between  the  cells.*  Dujardin,  in  1835,  discovered  a  moving  substance, 
to  which  he  gave  the  name  "  sarcode,"  in  the  lower  animals,  which  was 
thought  by  Huxley,  Meyer,  Schultze,  and  Miiller,  to  be  peculiar  to 
them,  and  possessed  of  "  irritability  without  nerves."  Siebold  observed 
similar  movements  in  the  yolk  globules  of  planaria,  which  led  Kolliker 
to  suppose  that  all  cell  contents  were  contractile.  Virchow  thought 
these  movements  due  to  a  contractile  substance ;  Leydig  thought  them 
phenomena  of  life,  but  all  believed  them  to  be  "something  different 
from  the  animal  cell,  as  a  body  sui  generis." 

Prigsheim,  in  1854,  declared  the  entire  vegetable  cell  contents  to 
consist  of  protoplasm  and  fluid,  and  denied  the  existence  of  a  primor- 
dial utricle,  though  admitting  that  the  protoplasm  might  be  ai'ranged 
in  layers,  but  that  these  layers  could  not  be  distinguished  as  a  distinct 
membrane.  Leydig,  in  1856,  denied  the  existence  of  a  cell  wall,  and 
believed  what  was  held  to  be  it  was  but  the  hardened  periphery  of 
protoplasm,  which,  together  with  the  nucleus,  constituted  the  cell. 
Schultze,  in  1861,  "defined  the  cell  as  protoplasm  enclosing  a  nucleus." 
"  The  cell,"  he  says  in  1863,  "  leads  in  itself  an  independent  life,  of  which 
the  protoplasm  is  especially  the  seat,  although  to  the  nucleus  also  un- 
*  Tysou's  Cell  Doctrine,  p.  69. 


DEVELOPMENT    OF    THE    CELL    DOCTRINE.  49 

doubtedly  falls  a  most  important  though  not  yet  precisely  determined 
rule.  Protoplasm  is  for  the  most  part  no  further  distinct  tlian  that  it 
will  not  mingle  with  the  surrounding  medium,  and  in  the  pecu- 
liarity that  with  the  nucleus  it  forms  a  unit.  Upon  the  surface  of  the 
protoplasm  there  may  form  a  membrane,  which,  although  derived  from 
it,  may  be  chemically  different,  and  the  assertion  that  it  is  the  heginning 
of  a  retrogression  xnfxy  be  defended."*  Briicke  had  previously  (1861) 
shown  that  the  nucleus  even  was  not  an  essential  part  of  the  cell,  and 
there  has  been  cited  in  evidence  the  non-nucleated  amoeba  and  proto- 
zoon,  and  two  non-nucleated  monads  described  by  Cienkowsky.  We 
come  now  to  the  consideration  of  that  doctrine  which  seems  to  us  to 
embody  the  greatest  amount  of  truth,  and  to  be  capable  of  explaining 
the  greatest  number  of  the  phenomena  of  life — a  doctrine  that  has 
been  slowly  evolved  by  the  labor  of  scientists  everywhere;  many  of  the 
ideas  entering  into  it  had  been  suggested  by  other  investigators  ;  but 
Dr.  Lionel  Beale — who,  more  than  any  other  investigator,  has  more 
fully  elaborated,  and  more  wisely  associated  the  facts  on  which  it  is 
based,  while  adding  largely  to  them  by  his  own  investigation — is  gen- 
erally recognized  as  the  exponent  of  that  doctrine  of  cell  organization 
and  growth  which  claims  a  "  vital "  influence  as  an  essential  factor  in 
the  resolution  of  the  problem  of  life — a  doctrine  to  which  we  give  our 
most  unqualified  adherence.  Dr.  Beale  makes  some  very  imj)ortant 
and  advantageous  changes  in  the  old  nomenclature ;  he  describes  the 
cell,  or,  as  he  prefers  to  call  it,  "  elementary  part,"  as  consisting  essen- 
tially of  "germinal  matter"  and  "formed  material."  "Germinal 
matter  "  represents  what  was  known  to  former  writers  as  "  cell  con- 
tents," "protoplasm,"  "endoplast,"  and  "nucleus."  It  is  the  living, 
growing  part  of. the  cell — that  part  which  appropriates  the  pabulum 
brought  to  it  by  the  blood,  and  with  it  reconstructs  itself,  continually 
repairing  the  waste  resulting  from  disintegration  of  "  formed  material," 
the  latter  corresponding  to  the  "cell  wall,"  primordial  utricle,  "peri- 
plast," and  "  intercellular  substance ;  "  the  germinal  matter  is  centrally 
situated,  the  formed  material  superficially,  and  results,  Dr.  Beale 
thinks,  from  the  death  of  the  germinal  matter,  and  this  is  the  single 
feature  of  his  doctrine  to  which  we  are  disjDosed  to  take  exception. 
We  do  not  see  with  what  propriety  the  formed  material  is  spoken  of  as 
"  dead,"  while  still  invested  with  the  properties  of  life,  contractility  in 
muscle,  neurility  in  nerve,  etc.,  as  has  been  well  objected  by  Dr.  Tyson, 
though  Dr.  Beale  himself  does  not  seem  to  look  upon  contractility  and 
neurility  as  vital  phenomena.  "I  might  go  further  than  many  of  those 
who  adopt  the  physical  theory  of  life,  and  admit  that  not  only  muscular 
and  nervous  action,  but  that  the  production  of  many  of  the  compounds 
*  Schultze,  ProtOpl.  d.  Rhizopoden. 

4 


50  PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 

found  iu  the  secretions  and  in  the  blood  are  due  to  physical  and 
chemical  changes  alone."  *  To  me  the  function  of  the  different  struc- 
tures seems  quite  as  wonderful,  and  as  inexplicable  on  purely  physical 
laws,  as  their  formation  ;  and  indeed  Dr.  Beale  seems  to  have  an  uneasy 
sensation  that  something  more  than  physical  law  is  involved  in  mus- 
cular contractility,  for  a  little  further  on  he  says  :  "  ISTo  one  knows 
better  than  the  physicist,  that  the  force  of  muscular  contraction  very 
far  exceeds  that  which  can  be  obtained  from  any  known  arrangement 
containing  the  same  weight  of  matter."  f  Nor  do  any  of  the  phenom- 
ena of  life  seem  more  remarkable  to  me  than  sensibility,  and  the  power 
of  originating  sentient  motion,  which  latter  is  surely  quite  as  wonderful 
as  that  living  particles  should  move  from  a  centre  in  opposition  to  the 
general  law  of  all  purely  physical  motion,  and  to  mention  the  higher 
intellectual  acts  to  which  the  application  of  the  term  nerve-function 
may  not  be  recognized  as  appropriate.  The  essential  features  of  this 
theory  are  that  all  structures  "spring  from  pre-existing  structures" 
which  are  capable  of  appropriating  to  themselves  things  differing  from 
themselves,  and  converting  them  into  structures  identical  with  them- 
selves, and  further,  that  they  are  capable  of  indefinite  multiplication. 
No  such  thing,  therefore,  as  spontaneous  generation  does  or  can  occur. 
Germinal  matter  is  of  "  granular  appearance,"  and  is  everywhere  the 
same ;  the  germinal  matter  of  nerve  tissue  cannot  be  distinguished 
from  the  germinal  matter  of  a  leaf  or  of  the  lowest  fungus.  All  ger- 
minal matter  was  once  pabulum,  as  all  tissues  were  once  germinal 
matter.  The  formed  material,  or  cell  wall  when  it  exists,  is  of  vari- 
able thickness,  and  may  continue  to  increase  in  thickness  by  the 
formation  from  the  germinal  matter  of  new  material  on  its  inner  sur- 
face, or  it  may  become  thinner  by  the  rapid  accumulation  of  germinal 
matter  within,  and  its  consequent  distention ;  or  both  may  take  place 
at  the  same  time,  the  cell  wall  remaining  passive.  The  formed  mate- 
rial endowed  with  such  properties  as  contractility  in  muscle  is  yet 
incapable  of  reproducing  itself  by  the  assimilation  of  pabulum,  while 
the  germinal  matter  is  the  laboratory  where,  under  some  inexplicable 
guidance,  the  inert  elements  of  the  tissues,  brought  thither  by  the 
blood,  are  converted  into  living  matter. 

Situated  in  the  centre  of  the  elementary  part,  all  food  must  pass 
through  the  formed  material  to  reach  the  germinal  matter ;  hence  the 
growth  of  the  cell  will  be  more  or  less  rapid,  other  things  being  equal, 
according  to  the  thickness  of  the  formed  material,  the  most  superficial 
and  oldest  part  of  the  cell.  The  form  of  the  particle  of  germinal 
matter  is,  in  Dr.  Beale's  opinion,  spherical,  though  he  acknowledges 
that  such  a  conclusion  is  purely  conjectural,  since  it  is  impossible  to 
*  Structure  and  Growth  of  Tissues,  p.  211.  f  Ibid,  p.  213. 


DEVELOPMENT   OF   THE    CELL    DOCTRINE.  51 

see  them  separately,  or  even  to  conceive  a  particle  of  living  matter  not 
compound. 

The  nutritive  changes  in  the  tissues  depend  for  their  proper  activity 
on  the  two  opposite  processes  of  disintegration  and  renewal ;  as  new 
particles  are  constantly  being  added  by  the  assimilative  action  of  the 
germinal  matter,  so  waste  is  constantly  taking  place  by  destructive 
metamorphosis  of  the  formed  material,  and  in  the  maintenance  of  a 
perfect  equilibrium  between  these  processes  consists  the  health  of  the 
part ;  but  if  the  blood  be  charged  with  some  poisonous  element  impair- 
ing the  nutritive  qualities  of  the  cell  food,  or  if  the  blood  be  deficient 
in  healthy  pabulum,  from  indigestion  or  improper  quality  of  ingesta, 
or  if  the  quantity  of  the  blood  circulating  through  the  part  prove 
inadequate  to  its  proper  support,  this  equilibrium  is  destroyed,  and 
disease  results.  "  A  change  of  this  sort  occurs  in  scarlet  fever.  The 
morbid  matter  circulating  in  the  blood  interferes  with  the  regular 
production  of  new  cuticle ;  for  a  time  none  is  formed,  but  by  and  by, 
when  the  violence  of  the  disease  abates,  and  the  poison  is  in  a  great 
measure  eliminated  from  the  blood,  the  formative  process  is  re-estab- 
lished. A  gap,  however,  exists,  as  it  were,  between  the  tissue  formed 
before  the  interference  of  the  disease  and  that  produced  after  the 
natural  process  was  resumed.  In  point  of  age  they  are  separated  by 
an  interval,  so  that,  as  the  new  cuticle  grows  up  from  below,  the  old  is 
separated  en  masse."  Though  the  germinal  matter  is  everywhere  the 
same  in  general  appearance,  and  grows  in  precisely  the  same  way,  yet 
the  structure  resulting  from  its  growth  is  very  different,  according  to 
the  situation  from  which  it  is  derived ;  the  germinal  matter  of  muscle 
will  form  nothing  but  muscle,  that  of  nerve  nothing  but  nerve ;  it  is 
seen,  therefore,  to  possess  peculiar  endowments,  according  to  the  locality 
in  which  it  originated,  though  all  these  structures  are  known  to  have 
had  a  common  origin  "  from  a  single  mass  in  the  embryo."  Nor  is 
this  peculiar  endowment  lost  by  transplantation ;  in  whatever  situation 
the  cell  may  subsequently  be  found,  if  it  grow  at  all,  it  does  so  in 
obedience  to  the  impulse  received  from  the  parent  cell,  refusing  to 
acknowledge  any  formative  control  from  the  structure  by  which  it 
may  be  invested.  The  germinal  matter  of  bone  will  produce  bone 
wherever  it  may  be  placed,  if  the  conditions  requisite  to  its  growth  and 
development  be  preserved.  Dr.  Beale  thinks  "bone  cancer"  is  an 
illustration  of  this  fact ;  and  that  it  is  due  to  the  escape  into  the  blood  of 
minute  particles  of  germinal  matter  from  bone,  which  is  subsequently 
deposited  in  some  tissue  where  conditions  favorable  to  development 
exist,  and  thus  is  formed,  in  an  abnormal  situation,  an  osseous  growth. 
Virchow's  theory  that  all  pathological  growths  are  the  result  of  exces- 
sive proliferation  of  the  connective  tissue  corpuscle  in  the  situation  in 


52  PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 

which  it  is  found,  fails  to  account  satisfactorily  foi'  such  phenomena  as 
these.  On  considering  the  changes  that  take  place  after  the  applica- 
tion of  a  blister,  we  shall  be  able  to  observe  the  formation  of  pus  globules 
and  the  development  of  cuticle.  After  the  application  of  the  irritant, 
a  fluid  is  poured  out  between  the  layers  of  the  cuticle;  upon  the  deep 
surface  of  the  superficial  layer  are  seen  little  masses  of  germinal  matter 
enveloped  in  a  thick  layer  of  formed  material ;  in  the  subjacent  fluid, 
also,  after  a  time,  will  be  found  a  great  number  of  these  elementary 
parts,  with,  however,  a  comparatively  thin  layer  of  formed  material, 
rapidly  multiplying.  These  are  pus  corpuscles  which  are  observed  to 
have  the  power  of  appropriating  the  nutrient  material  of  the  blood  and 
the  debris  of  the  tissues,  and  of  converting  it  into  material  like  them- 
selves. This  takes  place  much  more  rapidly  than  in  the  normal  state. 
The  nuti'itive  material  is  furnished  in  greater  abundance  than  usual, 
and  if  it  were  not  so  converted  it  would  undergo  decomposition,  and 
the  whole  of  the  surrounding  tissue  would  be  destroyed. 

Here  the  elementary  part  of  cuticle  is  formed  in  the  usual  way,  but 
too  rapidly  for  the  low  conversion  of  germinal  matter  into  the  tissue 
of  cuticle ;  a  soft,  spongy  matter  resembling  cuticle  is  formed,  which 
cannot  undergo  further  formative  transformation,  but  becomes  pus 
instead.  In  the  process  of  healing  the  reverse  of  this  takes  place :  a 
layer  of  formed  material  is  slowly  formed  on  the  surface  of  the  ele- 
mentary parts,  which  are  no  longer  produced  with  such  rapidity,  and 
is  gradually  converted  into  proper  cuticular  tissue.  The  relative  pro- 
portion of  germinal  matter  to  formed  material  is  much  greater  in  young 
tissue  than  in  old,  in  youth  than  in  the  adult.  The  development  of 
tissue  takes  place  rapidly  in  the  embryo,  where  the  germinal  matter  is 
abundant;  in  old  age  it  progresses  slowly, owing  to  the  proportionately 
small  quantity  of  germinal  matter  to  the  formed  material,  which  so 
envelops  it  as  to  obstruct  the  passage  of  nutrient  matter  to  it.  In  the 
fluids  of  the  body  we  find  germinal  matter  abundant  in  "  the  white 
corpuscles  of  the  blood,  the  corpuscles  of  the  lymph  and  chyle,  and  the 
contents  of  the  closed  glands  are  to  be  regarded  as  masses  of  germinal 
matter  possessing  important  powers  of  growth."  In  certain  diseased 
conditions  the  white  blood  corpuscles  undergo  very  rapid  development, 
whilst  their  further  change  into  red  blood  corpuscles  takes  place  very 
slowly,  thus  destroying  the  balance  between  disintegration  and  repair. 
"  Chyle  and  lymph  corpuscles,  certain  corpuscles  in  some  specimens  of 
mucus,  the  corj^uscles  in  certain  glandular  organs,  white  blood  cor- 
puscles and  pus  globules  "  bear  an  exceedingly  close  resemblance  to 
each  other,  for  a  very  obvious  reason ;  they  are  composed  almost  en- 
tirely of  germinal  matter ;  and  we  have  seen  that  germinal  matter  is 
*  Beale  on  the  Structure  and  Growth  of  Tissues,  p.  48. 


DEVELOPiMENT    OF    THE    CELL    DOCTRINE.  53 

the  same  in  appearance  wherever  found,  though  possessed  of  very  dif- 
ferent powers,  according  to  its  origin.  The  Avliite  blood  corpuscles  are 
purely  germinal  matter,  Avhich  Dr.  Beale  thinks  would  undergo  de- 
velopment into  tissue,  if  it  were  not  for  the  constant  motion  to  which 
they  are  subjected,  and  that  when,  from  any  cause,  they  become  sta- 
tionary, they  undergo  rapid  conversion  into  some  simple  form  of  fibrous 
tissue  ;  "  indeed,  there  is  reason  for  believing  that  fibrin  is  the  formed 
material  of  the  ivhite  blood  corpiisdesJ'^  Secretion,  according  to  Dr. 
Beale,  is  the  resultant  of  the  disintegration  of  the  secretory  organ  ; 
thus,  in  the  liver  this  process  is  described  as  a  transudation  from  the 
blood  of  the  material  of  which  the  bile  is  composed,  which  becomes 
converted  into  the  germinal  matter  of  the  liver  cell.  "  The  particles 
of  this  mass  are  constantly  growing  from  centre  to  circumference,  and 
when  they  have  reached  the  circumference  of  the  mass,  having  passed 
through  various  stages  of  their  existence,  they  become  bile."  The 
general  theory  of  development,  as  taught  by  Dr.  Beale,  is  briefly 
summed  up  by  himself  in  the  following  words:  "  1.  Matter  luhich pos- 
sesses the  power  of  forming  itself  into,  or  of  altering  the  arrangement  and 
relation  of,  its  own  constituent  elements,  so  as  to  form  matter  having  cer- 
tain peculiar  properties.  2.  Matter  or  tissue  which  has  thus  resulted  or 
been  formed.  The  latter  generally  forms  an  investment  around  and 
protects  the  former;  but  in  certain  cases,  besides  this  investment  being 
formed,  some  of  the  living  particles  undergo  change,  and  become  re- 
solved into  a  peculiar  formed  matter,  of  which  very  little  remains,  is 
found  between  the  external  investment  and  the  pecidiar  formed  matter 
within.  As  examples  of  this,  you  may  remember  I  adduced  the 
familiar  examples  of  the  fat  cell  and  the  starch  cell.  In  nutrition,  the 
pabulum  first  becomes  forming  matter,  and  in  this  new  state  passes 
through  certain  stages  of  existence,  and  at  last  becomes  formed.  The 
movement  of  the  particles  always  takes  place  in  one  constant  direction 
from  tlie  centre,  at  which  they  become  living.  The  pabulum  always 
passes  in  the  opposite  direction." 

*  Beale  on  the  Structure  and  Growth  of  Tissues,  p.  49 


54  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


CHAPTER  II. 

ANATOMY   AND   PHYSIOLOGY   OF   THE   MOUTH, 

THE  moutli  signifies,  in  the  human  subject,  the  space  included  be- 
tween the  palatine  arch  above,  the  mylo-hyoid  muscles  beneath,  the 
lips  in  front,  the  velum  palati  behind,  and  the  cheeks  on  either  side. 
The  teeth  and  closed  jaws  separate  the  inner  portion,  or  lingual  cavity, 
from  the  outer,  or  vestibular  space ;  and  while  that  part  of  the  latter 
bounded  by  the  cheeks  ought  properly  to  bear  the  appellation  buccal, 
the  term  buccal  cavity  is  not  unfrequently  employed  with  a  significa- 
tion so  general  as  to  comprehend  the  whole  oral  cavity. 

In  the  mouth  are  the  tongue,  teeth,  and  the  alveolar  ridges  invested 
by  the  gums;  into  it  are  poured  the  secretion  of  the  parotid,  sub- 
maxillary and  sublingual  glands,  as  well  as  that  of  the  ordinary 
mucous  and  of  the  special  lingual  follicles ;  and  in  it  the  food  is  sub- 
jected to  the  processes  of  mastication  and  insalivation  previous  to 
deglutition. 

It  is  further  concerned  in  the  prehension  of  aliment ;  and  besides 
containing  the  organs  of  taste,  is  employed  in  articulation,  expectora- 
tion, suction,  etc. 

The  parts  concurring  to  constitute  the  mouth  form  a  very  compli- 
cated piece  of  mechanism ;  through  them  it  has  a  wide  range  of  sym- 
pathies, and  by  them  it  performs  a  great  variety  of  functions. 

The  anatomical  elements  composing  these  parts  consist  of  Bone, 
Ligament,  Muscle,  Gland,  Blood  vessel.  Nerve,  Areolar  and  Adipose 
tissues,  and  Mucous  membrane. 

These  different  elements  combine  together  and  form  the  various 
organs  which  constitute  the  mouth. 

These  organs  I  shall  consider  in  their  physiological  order ;  thus 
combining  their  anatomy  and  physiology,  studying  at  the  same  time 
both  their  healthy  structure  and  function. 


OSTEOLOGY.  55 


CHAPTER  III. 

OSTEOLOGY. 

BONE  is  one  of  tbe  hardest  substances  in  the  body.  It  is  composed 
of  animal  oi*  organic  matter  in  intimate  association  with  earthy, 
or  inorganic  matter.  From  the  organic  matter  the  bone  derives  the 
properties  of  toughness  and  elasticity;  and  from  the  earthy  material, 
hardness  and  solidity.  The  mineral  matter  may  be  dissolved  out  by 
a  dilute  solution  of  nitric  or  muriatic  acids,  while  the  animal  matter 
remains  unaffected,  retaining  its  form,  though  losing  its  hardness,  so 
that  the  long  bones,  so  great  is  their  flexibility,  may  be  tied  into  a 
knot;  on  the  other  hand,  by  subjecting  them  to  a  high  heat  in  an  open 
fire,  while  exposed  to  the  air,  the  animal  matter  may  be  consumed, 
leaving  the  mineral  to  preserve  the  form  of  the  bone,  but  so  insecurely 
that  it  will  crumble  to  ashes  in  the  grasp  of  the  hand. 

The  composition  of  bone,  according  to  Berzelius,  is  about  one-third 
animal  and  two-thirds  mineral  matter  : — 

Animal  matter,  Gelatin  and  Blood  vessels,            .         .         .  33.30 

f  Phosphate  of  Lime,         .....  51.04 

Inorganic  Carbonate  of  Lime,      .....  1L30 

or                    -|  Fluoride  of'Calcium, 2.00 

Earthy  Matter.       I  Phosphate  of  Magnesia,        ....  1.16 

[  Soda  and  Chloride  of  Sodium,          .         .         .  1.20 

The  proportion  of  earthy  and  animal  matter  is  generally  thought 
to  vary  with  varying  age.  According  to  Shreger,  this  difference  is  as 
follows  : — 


CHILD. 

ADULT. 

OLD    AGE. 

Animal  Matter, 

.     47.20 

20.18 

12  2 

Earthy  Matter, 

48.48    . 

.     74  84    . 

.    84.1 

To  this  supposed  difference  has  commonly  been  ascribed  the  greater 
brittleness  of  bones  in  aged  people ;  but  recent  analyses  tend  to  show 
that  bone  is  at  all  periods  of  individual  life  chemically  the  same,  and 
if  so,  the  inference  growing  out  of  the  error  of  former  analyses  is  false. 

The  development  of  bone  takes  place  in  a  manner  somewhat  differ- 
ent from  that  of  most  other  tissues,  since  we  have,  in  addition  to  the 
germinal  matter  and  formed  material,  a  deposit  of  earthy  matter  in 
the  latter.  The  formation  of  the  animal  matter  is  a  vital  phenomenon, 
the  deposit  of  earthy  matter  a  purely  physical  one. 

The  "  cell  "  or  "  elementary  part "  of  bone  consists  of  a  soft  central 


56  PEIXCIPLES   AXD    PEACTICE    OF    DENTISTRY. 

mass  of  germinal  matter,  surrounded  by  a  thin  layer  of  soft  formed 
material  -svith  which  it  is  continuous,  and  which  "passes  uninterrupt- 
edly into  the  hard  calcified  formed  material."  This  hard  formed  ma- 
terial is  everywhere  perforated  by  little  channels  called  canaliculi, 
along  which  the  nutrient  material  is  conveyed  to  the  germinal  matter. 
These  canaliculi  are  formed  in  a  manner  corresponding  to  the  deposi- 
tion of  the  mineral  matter,  that  is,  from  without  inward,  commencing 
at  a  point  most  distant  from  the  germinal  matter.  In  the  dried  bone 
these  canals  are  seen  to  communicate  with  little  vacant  spaces  called 
lacunae,  occupied  in  the  fresh  state  with  germinal  matter,  seeming  to 
associate  them  with  one  another.  In  this  manner,  each  lacunje  com- 
municates freely  with  adjacent  lacunae. 

The  only  jiart  of  the  bone,  in  Dr.  Beale's  opinion,  which  can  be  said 
to  be  living,  is  the  "  nucleus  "  or  "bone  cell"  in  the  space  or  lacuna, 
constituting  perhaps  one-twelfth  part  of  the  bone;  all  the  rest  being 
as  dead  in  the  living  body  as  when  removed  from  it.  "  It  (the  germi- 
nal matter)  alone  can  grow  and  give  rise  to  the  formation  of  matrix. 
Bone  cannot  produce  bone,  but  the  germinal  matter  of  bone  may  become 
converted  into  neiv  bone  tissue."  Virchow  is  of  the  opinion  that  the 
matrix  is  true  intercellular  substance  into  which  proceed  stellate  pro- 
cesses from  the  cells  occupying  the  lacunas,  thus  giving  rise  to  the 
canaliculi ;  an  opinion  directly  opposite  to  that  of  Dr.  Beale,  that  the 
canaliculi  begin  in  the  matrix  (which  is  not  formed  independently  of 
the  cell,  but  consists  simply  of  the  formed  matei'ial,  or  cell  wall,  in 
which  mineral  matter  has  been  deposited),  and  extend  to  the  germinal 
matter  occupying  the  lacunal  space.  This  germinal  matter  is  always 
present  in  the  lacuna ;  on  it  depends  the  circulation  of  the  calcareous 
matter  held  in  solution  by  the  blood ;  without  it  bone  tissue  cannot  be 
formed,  and  on  its  presence  the  life  of  the  bone  depends.  The  cana- 
liculi, then,  are  the  "altered  spaces  or  ducts  which  are  left  between  the 
calcareous  globules  originally  deposited,  and  through  them  pass  fluids 
to  and  from  the  germinal  matter."  (Beale  on  the  Structure  and 
Growth  of  Tissues,  128.)  Originally  triangular  in  form,  they  finally 
become  so  altered  by  the  filling  up  of  the  angles  as  to  exhibit  a  circular 
appearance  on  transverse  section.  The  osseous  tissue  with  its  cana- 
liculi and  germinal  matter  always  bears  a  fixed  and  definite  relation  to 
the  vessels.  It  may  exist  as  solid  cylindrical  processes  covered  with  a 
vascular  membrane,  or  as  thin  laminae  also  covered  with  a  vascular 
membrane,  or  as  concentric  laminae  arranged  around  a  central  opening, 
a  "  Haversian  canal."  Each  Haversian  canal  has  a  diameter  of  about 
one-five-hundredth  of  an  inch  ;  though  they  are  of  very  different  sizes, 
varing  from  one-fifteen-huudredth  to  one-two-hundredth  of  an  inch 
in  diameter. 


BONES    OF   THE    HEAD    AND    FACE.  57 

The  elementary  parts  of  bone  are  so  arranged  as  to  form  eitlier  the 
loose  and  spongy  or  cancellated  bone  tissue,  or  the  more  solid  and  com- 
pact or  laminated  tissue,  as  in  the  shaft  of  a  long  bone ;  and  between 
these,  in  health,  a  transitional  stage  may  always  be  observed,  while  in 
disease  the  compact  tissue  may  undergo  such  modification  as  to  re- 
semble the  cancellated.  There  are  also  "  lai-ge  spaces  like  cancelli"  in 
the  compact  tissue,  called  the  "  Haversian  spaces,"  which  are  merely 
the  canals  enlarged  by  erosion  taking  place  from  within  outward. 
The  canals  and  spaces  which  finally  form  the  fat  cells  may  also  undergo 
conversion  into  bone  tissue,  and  are  originally  derived  from  the  same 
elementary  parts  as  those  from  which  bone  is  formed. 


CHAPTER  IV. 

BONES  OF  THE  HEAD  AND  FACE. 

THE  osseous  structures  in  which  the  student  of  dentistry  is  especially 
interested,  and  to  which  we  would  direct  attention,  are — 

1.  The  superior  maxillary  or  upper  jaw  bones. 

2.  The  inferior  maxillary  or  lower  jaw  bones. 

3.  The  palate  bone. 

Development  of  the  Bones  of  the  Head  and  Face. — The  first  definite 
form  which  is  developed  in  the  embryo  is  that  of  the  rudimentary 
spinal  column,  its  earliest  trace  being  a  faint  streak,  which  is  known 
as  the  primitive  trace  or  groove.  This  groove  deepens  into  a  furrow, 
which  is  bounded  by  two  plates,  beneath  which  a  delicate  fibril  appears, 
called  the  chorda  dorsalis  or  notochord,  in  which  cartilage  is  very  early 
developed. 

The  upper  end  of  the  chorda  dorsalis  terminates  in  a  pointed  ex- 
tremity extending  as  far  forward  as  the  sphenoid  bone. 

The  embryonal  cranium  is  developed  from  the  primitive  vertebral 
disks,  which  surround  the  upper  extremity  of  the  chorda  dorsalis. 
These  disks  advance  in  the  form  of  a  membranous  capsule,  which  moulds 
itself  on  the  cerebral  vesicles,  so  as  to  constitute  the  membrane  in 
which  the  vault  of  the  skull  is  developed,  and  which  is  replaced  by 
cartilage  in  the  part  corresponding  to  the  base  of  the  skull.  A  por- 
tion of  this  primitive  cartilaginous  cranium  atrophies  and  disappears, 
while  another  portion  remains  and  forms  the  cartilages  of  the  nose 
and  the  articulations,  the  basilar  part  of  the  occipital,  the  greater  part 


58  PRINCIPLES   AXD   PRACTICE   OF   DENTISTRY. 

of  the  sphenoid,  the  petrous  and  mastoid  portions  of  the  temporal,  the 
ethmoid,  and  the  septum  nasi. 

From  the  anterior  end  of  the  chorda  dorsalis  the  four  pharyngeal 
arches  proceed  on  either  side  and  meet  in  the  middle  line. 

In  these  pharyngeal  arches  the  secondary  bones  are  developed,  so 
called  to  distinguish  them  from  those  already  referred  to,  which  are 
formed  from  the  primitive  cranium  itself.  The  buccal  depression, 
which  afterwards  becomes  the  cavity  of  the  mouth,  or  rather  the 
fauces,  is  situated  between  the  first  pharyngeal  arch  and  the  frontal 
protuberance. 

Fig.  1. 


---.V 


FACE   OF  AN    EMERVO    OF   25   TO   28    DAYS.      (MAGNIFIED   15  TIMES.) 

1.  Frontal  prominence.  2,  3.  Kight  and  left  olfactory  fossae.  4.  Inferior  maxillary  tubercles, 
united  in  tlie  middle  line.  5.  Superior  maxillary  tubercles.  6.  Mouth  or  fauces.  7.  Second 
pharyngeal  arch.    8.  Third.    9.  Fourth.    10.  Primitive  ocular  vesicle.    11.  Primitive  auditory  vesicle. 

The  first  pharyngeal  arch  divides  at  its  anterior  extremity  into  two 
parts — a  superior  and  inferior  maxillary  protuberance,  the  inferior 
maxillary  uniting  very  early  to  the  corresponding  one  of  the  opposite 
side,  to  form  the  lower  jaw. 

The  superior  maxillary  protuberances  are  united  to  the  external 
nasal  process,  and  the  palate  bone,  the  superior  maxillary,  the  malar, 
and  also  the  internal  plate  of  the  pterygoid  process,  are  developed 
from  this  process.  From  the  internal  nasal  process,  the  nasal  bones, 
the  lateral  portions  of  the  ethmoid,  and  the  os  unguis  are  developed. 
From  the  incisive  tubercle,  which  unites  the  rest  of  these  processes  on 


BONES    OF   THE    HEAD    AND    FACE. 


59 


either  side,  the  intermaxillary  bone,  the  middle  of  the  upper  lip,  and 
the  vomer,  are  formed. 

At  an  early  period  of  embryonal  life  the  maxillary  arch  is  alto- 
gether destitute  of  any  trace  of  osseous  tissue,  but  it  encloses  within 
the  elements  composing  it  a  symmetrical  cartilaginous  band,  which 
performs  a  transitory  part  only  in  the  development  of  the  jaw. 

This  band  is  called  "  Meckel's  Cartilage,"  and  it  occupies  the 
interior  of  the  maxillary  arch,  having  the  form  of  a  whitish  cord 
situated  in  a  bed  of  soft  transparent  tissue,  and  is  composed  of  two 
symmetrical  parts  corresponding  to  the  right  and  left  sides  of  the 
lower  jaw,  which  parts  soon  become  united  at  the  mental  symphysis. 
From  this  point  of  juncture  the  two  halves  extend  on  either  side  to 
the  bones  of  the  ear,  terminating  in  the  malleus,  which,  with  the 
incus,  is  formed  from  it. 

Meckel's  cartilage  gives  form  and  stability  to  the  lower  jaw  of  the 
embryo,  and  is  the  first  solid  structure  discovered  in  the  maxillary 

Fia.  2. 


MF.CKEL's  cartilage,  from  embryo  of  40  TO  42  DATS,  BEFORE  APPEARANCE  OF  MAXILLARY  BONE. 

a.  Enlargement  of  cartilage  near  neck  of  malleus  ;  6.  a  slightly  enlarged  portion  of  cartilage,  but 
contracted  at  median  line,  wbere  it  unites  with  that  of  opposite  side ;  n.  handle  of  malleus ;  o.  carti- 
lage of  the  OS  lenticnlare ;  I.  cartilage  of  the  stapes ;  s.  outline  of  the  jaw  to  be  formed. 


arch.  It  first  appears  about  the  twenty-fifth  day,  and  during  its 
existence,  which  extends  to  a  period  between  the  seventh  and  eighth 
months  of  foetal  life,  it  is  subject  to  constant  modifications  or  transitory 
states. 

As  soon  as  the  cartilage  has  attained  its  full  development,  a  period 
which  corresponds  to  the  ossification  of  the  malleus,  it  begins  to  waste 
away,  and  finally  wholly  disappears. 

In  the  upper  jaw  the  period  of  evolution  corresponds  with  that  of 
the  lower  jaw,  Meckel's  cartilage  belonging  exclusively  to  the  lower  jaw. 


60 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


Fig.  3. 


Fig.  4. 


INTERNAL  PACE  OF  RIGHT  INFERIOR  MAXILLA 
OF  EMBRYO  OF  THREE  MONTHS. 

a.  Extra-tympanic  portion;  b.  symphysis  of 
the  cartilage :  u.  handle  of  malleus ;  e.  carti- 
lage of  incus. 


FROM  HUMAN  EMBRYO  OF  SIXTY  DAYS,  NATURAL  SIZE. 

a.  Extra-tympanic  portion  of  Meckel's  cartilage;  6.  symphysis;  c.  handle  of  malleus. 

At  a  period  between  the  thirty-fifth  and  fortieth  days  of  embryonal 
life,  slight  traces  of  ossification  are  observed  at  points  midway  between 
the  angle  and  symphysis  of  the  future  jaw,  and  the  ossification  extends 
rapidly  in  both  directions,  anterior  and  posterior,  along  the  external 
face  of  Meckel's  cartilage,  and  in  contact  but  not  united  with  it. 

At  about  the  second  month  of  ges- 
tation, the  rudimentary  jaw  bone  is 
formed,  but  not  completed ;  it  is  com- 
posed of  two  arches,  an  internal  carti- 
laginous one,  composed  of  Meckel's 
cartilage;  and  an  external  one,  com- 
posed of  osseous  matter ;  the  former 
being  only  needed  for  a  time,  to  sup- 
port the  jaw,  and  the  latter  the  rudi- 
ment of  the  bone  of  the  jaw. 

While  later  in  life  there  are  two 
superior  maxillary  bones,  in  early 
fcetal  life  there  exists  what  are  called  inter-maxillary  bones,  the  upper 
jaw  during  its  development  being  composed  of  four  bones — two  max- 
illary and  two  inter-maxillary.  In  each  of  the  two  inter-maxillary 
bones  are  developed  two  incisors — a  central  and  a  lateral,  and  in  each 
of  the  two  maxillary  bones — a  canine  and  two  molars — later  a  canine, 
two  bicuspids  and  three  molars.  Before  birth  the  intei'-maxillary  and 
the  maxillary  bones  unite,  reducing  the  number  to  two  instead  of  four, 
and  the  inter-maxillary  suture,  whei*e  the  union  takes  place,  can  be 
seen  at  birth  on  the  palatal  surface  but  not  on  the  outer  surface. 

These  inter-maxillary  bones  are  designated 
by  Huxley  a.s,  premaxillcB,  and  in  some  animals 
they  remain  jDermanently  as  separate  bones. 

The  buccal  cavity  comprises  the  mouth 
and  nose  until  a  lamina  is  formed  from  the 
superior  maxillaiy  tuberosity  on  either  side 
which  has  a  horizontal  inward  direction. 
The  two  palatine  lamellae  meet  in  the  median 
line,  in  front,  about  the  eighth  week,  and  the 
septum  is  completed  about  the  ninth  week. 
The  superior  maxillary  bones  and  the  soft 
parts  covering  them  unite  at  an  early  period 


Fig 


FROM  FffiTUS  OF  FOUR  MONTHS, 
SHOWING  INTERMAXILLARY  SU- 
TURE ON  PALATAL  SURFACE, 
WHERE  THE  INTER-MAXILLARY 
BONES  HAVE  UNITED  WITH  THE 
MAXILLARY  BONES. 


THE   SUPERIOR    MAXILLARY   BONES. 


61 


^vith  the  inter-maxillary  or  incisive  bone,  and  the  median  portion  of 
the  lower  lip.  The  nostrils  are  formed  by  the  olfactory  fossse  opening 
into  the  upper  or  respiratory  portion  of  the  cavity. 

THE   SUPERIOR   MAXILLARY   BONES. 

The  Superior  Maxillary  Bones,  two  in  number,  are  in  pairs,  and 
united  on  the  median  line  of  the  face.  They  occupy  the  anterior 
upper  part  of  the  face,  are  of  very  irregular  form,  and  consist  of  a 
body  and  processes.  They  are  the  largest  bones  of  the  face  except  the 
inferior  maxilla,  and   enter  into  the  formation  of  three  cavities,  the 


OUTER 


Fig.  6. 
sunrAC£ 


TENDO    OCUlI-J-Q% 


WCISIVE  FOSSA 


.-fOR'.;  I  UIAXILLARY   TUBEROSITY 


anime,    bicuspids. 


orbit,  the  mouth  and  the  nares ;  they  also  enter  into  the  formation  of 
the  zygomatic  and  spheno-maxillary  fossse,  and  the  spheno-maxillary 
and  pterygo-maxillary  fissures. 

The  body  is  the  central  part  of  the  bone,  and  has  four  surfaces ; 
namely,  the  external  or  facial,  the  posterior  or  zygomatic,  the  superior 
or  orbital,  and  the  internal  or  palatine. 

The  External  Surface  is  irregularly  convex,  and  has  a  depression 
about  its  centre,  just  above  the  canine  and  first  bicuspid  teeth,  called 
the  canine  fossa  ;  immediately  above  which  is  the  infra-orbital  foramen 


62 


PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


for  transmitting  an  artery  and  nerve  of  tlie  same  name ;  its  upper  and 
inner  edge  forms  part  of  the  lower  margin  of  the  orbit,  to  which  is 
attached  the  levator  labii  superioris  proprius  muscle. 


The  Posterior  Surface  has  a  bulging,  called  tuberosity,  which  is  con- 
nected w^ith  the  palate  bones,  and  bounds  the  antrum  behind  ;  it  is 
perforated  by  three  or  four  small  holes — the  posterior  dental  canals, 
which  transmit  nerves  and  blood  vessels  to  the  molar  teeth.  This 
surface  presents  also  on  its  nasal  face  a  groove,  which  becomes,  by 
articulation  with  the  palate  bone,  the  posterior  palatine  canal. 


Fig.  7. 


BONES  PART/ALi-V  C/.OSINC   ORIFICE  OF 
A!\iTRUM    MARKCD   IN    OUTLINE 


':^(?/i^> 


ANTER.  NASAL 
SPINE 


BRISTLE  PASSED 
rHROUCH  ANTE. 
P/ILAT.  CANAL 


The  Internal  Surface  extends  from  the  alveolar  processes  in  front  to 
the  horizontal  plate  of  the  palate  bones  behind,  called  the  palatine 
processes,  which  are  rough  below,  forming  the  roof  of  the  mouth,  and 
smooth  above,  making  the  floor  of  the  nostrils.  They  are  united  along 
the  median  line,  at  the  anterior  part  of  which  is  the  foramen  incisivum, 
having  two  openings  in  the  nares  above,  while  there  is  but  one  in  the 
mouth  below.  The  body  of  the  superior  maxilla  is  occupied  by  a 
large  and  very  important  cavity  called  the  Antrum  Highmorianum,  or 
Maxillary  Sinus.  This  cavity  is  somewhat  triangular  in  shape,  with 
its  base  generally  looking  to  the  nose,  and  its  apex  to  the  malar  pro- 


THE    SUPEiaOR    MAXILLARY    BONES.  63 

cess.  Its  upper  wall  is  formed  by  the  floor  of  the  orbit,  its  lower  by 
the  alveoli  of  the  molar  teeth,  which  sometimes  perforate  this  cavity. 
The  canine  fossa  bounds  it  in  front,  while  the  tuberosity  closes  it 
behind.  But  the  shape  of  this  cavity  is  exceedingly  variable.  In  ex- 
amining a  collection  of  nearly  one  hundred  maxillse  in  the  Museum 
of  the  Baltimore  Dental  College,  no  two  sinuses  were  found  to  be 
shaped  alike ;  and  this  difference  is  as  marked  between  the  right  and 
the  left  in  the  same,  as  in  different  subjects.  The  floor  of  some  is 
nearly  flat,  but  in  the  majority  of  cases  it  is  very  uneven  ;  sometimes 
crossed  by  a  single  septum,  varying  from  one-eighth  to  half  an  inch  in 
height;  at  other  times  there  are  found  three  or  four  septa,  dividing  the 
lower  part  of  the  cavity  into  as  many  separate  compartments,  with  the 
bottom  or  floor  of  no  two  on  a  level  with  each  other.  Some  are  per- 
forated by  the  roots  of  one  or  more  teeth ;  at  other  times  the  roots  of 
several  teeth  extend  considerably  above  the  level  of  the  floor  of  the 
antrum,  covered  by  a  lamina  of  bone  scarcely  thicker  than  bank-note 
paper.  In  other  cases,  the  floor  of  the  antrum  is  half  an  inch  above 
the  extremities  of  the  roots  of  the  teeth.  This  cavity  also  varies  as 
much  in  size  as  it  does  in  shape. 

The  opening  of  the  antrum  is,  on  its  nasal  portion  or  base,  into  the 
middle  meatus  of  the  nose ;  in  the  skeleton  it  is  large,  while  in  the 
natural  state  it  is  much  contracted  by  the  ethmoid  bone  above,  the 
inferior  turbinated  bone  below,  the  palate  bone  behind,  and  by  the 
mucous  membrane  which  passes  through  the  opening  and  lines  the  in- 
terior of  the  antrum,  A  deep  groove  lies  in  front  of  the  opening  in 
the  antrum,  which  is  converted  into  a  canal  for  the  nasal  duct  by  the 
lachrymal  and  inferior  turbinated  bones. 

The  Malar  Process  is  a  rough,  triangular  process,  marking  the 
boundary  between  the  external  and  internal  surfaces.  It  presents  on 
its  upper  margin  a  roughened  surface  for  articulation  with  the  malar 
bone. 

The  Nasal  Process  forms  the  lateral  boundary  of  the  nose.  It  is  a 
thick,  triangular  prominence  articulating  at  its  upper  extremity,  by  a 
serrated  edge,  with  the  frontal  bone,  and  by  an  uneven  surface,  with 
the  ethmoid  bone  ;  a  little  lower  on  its  internal  surface  it  offers  a 
transverse  ridge,  the  superior  turbinated  crest,  for  articulation  with 
the  middle  turbinated  bone ;  below  this  is  the  inferior  turbinated 
crest,  to  which  is  attached  the  inferior  turbinated  bone  ;  and  lying 
between  these  crests  is  a  smooth,  concave  space,  forming  part  of  the 
middle  meatus,  while  beneath  the  inferior  crest  is  a  like  space  which 
forms  part  of  the  inferior  meatus.  By  its  anterior  border  it  is  articu- 
lated with  the  nasal  bone,  and  by  its  posterior  with  the  lachrymal 
bone,  forming  with  it  the  canal  for  the  nasal  duct,  while  at  the  junction 


64 


PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


of  the  anterior  lip  of  the  nasal  groove  with  the  orbital  surface  is  placed 
the  lachrymal  tubercle,  serving  as  a  guide  to  the  duct  in  all  operations 
for  fistula  lachrynialis. 

The  Alveolar  Process  is  formed  on  the  lower  edge  of  the  external 
surface ;  it  is  broader  behind  than  in  front,  and  is  perforated  wdth  ex- 
cavations corresponding  in  number  with  the  teeth ;  those  depressions 
w^hich  receive  the  teeth  of  more  than  one  fang  are  subdivided  by  bony 
septa  into  compartments  of  a  sufficient  number  to  receive  these  fangs. 

The  bottom  of  each  of  these 
cavities  is  perforated  by  a  small 
foramen,  for  the  passage  of  nerves 
and  blood  vessels  which  supply 
the  teeth.  The  alveolar  border 
externally  presents  a  fluted  ap- 
pearance ;  the  projections  cor- 
respond with  the  alveolar  cavi- 
ties, and  the  depressions  with 
the  -septa  which  divide  them 
from  one  another. 
The  Palate  Process  forms  the  roof  of  the  mouth  and  part  of  the  floor 
of  the  nose ;  it  is  thick  and  strong,  and  presents  in  front  the  orifice  of 
the  anterior  palatine  canal  through  which  passes  the  anterior  palatine 
vessels,  whilst  the  inferior  naso-palatine  nerves  pass  along  the  inter- 
maxillary suture.  The  inferior  surface  at  the  back  part  has  a  deep 
groove,  sometimes  a  canal,  for  the  passage  of  the  posterior  palatine 
vessels,  and  a  nerve  of  large  size;  it  is  also  perforated  with  numerous 
foramina  for  the  passage  of  nutrient  vessels.  The  outer  border  is 
closely  attached  to  the  rest  of  the  bone.  The  inner  border,  thicker  in 
front  than  behind,  presents  a  ridge,  which,  together  with  a  similar  ridge 
on  the  opposite  bone,  forms  a  groove  in  which  the  vomer  is  received. 
The  anterior  margin  is  prolonged  into  a  sharp  process,  the  nasal  spine. 
By  its  posterior  border  it  articulates  with  the  horizontal  plate  of  the 
palate  bone. 

The  structure  of  the  upper  jaw%  with  its  alveolar  and  numerous 
other  processes,  is  thick  and  cellular ;  the  cancellated  structure  being 
invested  with  a  thin  layer  of  compact  bone. 

It  is  articulated  with  two  bones  of  the  cranium,  the  frontal  and 
ethmoid,  and  seven  of  the  face,  namely :  the  nasal,  malar,  lachrymal, 
palate,  inferior  turbinated,  vomer,  and  to  its  fellow,  by  sutures ;  also 
to  the  teeth  by  the  articulation  termed  gomphosis. 

Its  development  commences  at  so  early  a  period  of  intra-uterine  life, 
and  ossification  proceeds  so  rapidly,  that  the  number  of  ossific  centres 
is  uncertain  ;  some  give  a  centre  for  the  body  and  each  process,  others 


THE    INFERIOR    MAXILLARY    BONE. 


65 


think  that  most  probably  there  are  but  four  centres  in  all.  It  may  be 
seen  as  early  as  the  thirty-fifth  or  fortieth  day  after  conception ;  and 
although  at  birth  it  has  acquired  but  little  height,  it  has  increased 
considerably  in  breadtn.  But  at  this  period  the  alveolar  border,  which 
constitutes  the  largest  portion  of  the  bone,  is  almost  in  contact  with  the 
orbit.  The  antrum  is  still  scarcely  perceptible,  but  as  the  vertical  di- 
mensions of  the  bone  are  increased,  it  is  gradually  developed.  With  the 
loss  of  the  teeth,  the  alveolar  border  nearly  disappears,  so  that  the  vault 
of  the  palate  loses  its  arched  form,  and  sometimes  becomes  almost  flat. 
The  Lpper  or  Orbital  Surface  is  triangular  in  shape,  with  its  base  in 
front  forming  the  anterior,  lower  and  internal  edges  of  the  orbit,  while 
its  apex  extends  back  to  the  bottom,  forming  the  floor  of  the  orbit  and 


Fig.  9. 


CO.Vo,^ 


—ANGLE 


roof  of  the  antrum  ;  its  internal  edge  is  united  to  the  lachrymal, 
ethmoid  and  palate  bones ;  its  external  edge  assists  in  forming  .the 
spheno-maxillary  fissure,  and  along  its  central  surface  is  seen  a  canal 
running  from  behind,  forward  and  inward — the  infra- orbital  canal. 
This  canal  divides  into  two ;  the  smaller  is  the  anterior  dental, 
which  descends  to  the  anterior  alveoli  along  the  front  wall  of  the 
antrum;  the  other  is  the  proper  continuation  of  the  canal,  and  ends 
at  the  infra-orbital  foramen. 


THE   INFERIOR   MAXILLARY   BONE. 

The  Inferior  Maxillary  Bone  (Fig.  9)  is  the  largest  bone  of  the  face, 
and  though  single  in  the  adult,  it  consists  of  two  symmetrical  pieces 
in  the  foetus. 


66 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


It  occupies  the  lower  part  of  the  face,  has  a  parabolic  form,  and 
extends  backward  to  the  base  of  the  skull. 

It  is  divided  into  a  body  and  extremities. 

The  body  is  the  middle  and  horizontal  portion ;  this  is  divided  along 
its  centre  by  a  ridge  called  the  symphysis,  which  is  the  place  of  separa- 
tion in  the  infant  state ;  the  middle  portion  projects  at  its  inferior  part 
into  an  eminence  called  the  mental  process  or  chin ;  on  each  side  of 
which  is  a  depression  for  the  muscles  of  the  lower  lip ;  and  externally 
to  these  depressions  are  two  foramina,  called  anterior  mental,  for  trans- 
mitting an  artery  and  nerve  of  the  same  name. 

The  horizontal  portions  extend  backward  and  outward,  and  on  the 
outward  surface  have  an  oblique  line  for  the  attachment  of  muscles. 


Fig.  10. 


^\''';j^ojf 


MYLO-HYO/a  mocE 


BO o  y 


On  the  inner  surface  of  the  middle  part,  behind  the  chin,  along  the 
line  of  the  symphysis,  there  is  a  chain  of  eminences  called  genial  tuber- 
cles, to  the  superior  of  which  the  frsenum  linguae  is  attached,  to  the 
middle  the  genio-hyo-glossi,  and  to  the  inferior  the  genio-hyoid  mus- 
cles ;  on  each  side  of  these  eminences  are  depressions  for  the  sublingual 
glands ;  and  beyond  these  depressions  there  runs  an  oblique  ridge 
upward  and  outward,  to  the  anterior  part  of  which  is  attached  the 
mylo-hyoid  muscle,  and  to  the  posterior  part,  the  superior  constrictor 
of  the  pharynx ;  this  latter  muscle  is  consequently  involved  more  or 
less  in  the  extraction  of  the  last  molar  tooth.     Below  this  line  there  is 


THE    INFERIOR    MAXILLARY    BONE.  67 

a  groove  for  the  mylo-hyoid  nerve,  and  a.  depression,  the  sul)niaxillary 
fossa,  for  the  reception  of  the  submaxillary  gland. 

The  alveolar  border,  in  the  foetus,  constitutes  nearly  the  whole  body 
of  the  bone.  After  the  loss  of  the  teeth,  this  part  of  the  inferior  max- 
illary is  gradually  wasted.  The  alveolar  border,  in  the  lower  jaw, 
describes  a  rather  smaller  arch  than  it  does  in  the  upper,  and  both  its 
anterior  walls  are  thinner  than  the  j^osterior.  Passing  over  the  infe- 
rior border,  near  the  junction  of  the  body  with  the  ramus,  is  a  groove 
for  the  facial  artery. 

The  extremities  of  the  body  have  two  lai'ge  processes  rising  up  at  an 
obtuse  angle,  named  the  rami  of  the  lower  jaw.  These  j)rocesses  are 
flat  and  broad  on  their  surfaces ;  the  outer  one  is  covered  by  the  mas- 
seter  muscle ;  the  inner  one  has  a  deep  groove  which  leads  to  a  large 
hole,  the  posterior  dental  or  maxillary  foramen,  for  transmitting  the 
inferior  dental  nerves  and  vessels  to  the  dental  canal  running:  aloncr 
the  roots  of  the  teeth.  This  foramen  is  protected  by  a  spine  to  which 
the  spheno-maxillary  ligament  is  attached. 

The  i-amus  has  a  projection  at  its  lower  part,  which  is  the  angle  of 
the  lower  jaw  ;  its  upper  ridge  is  curved,  having  a  process  at  each 
end — the  anterior  one  is  the  eoronoid  process ;  this  is  triangular,  and 
has  the  temporal  muscle  inserted  into  it ;  the  posterior  is  the  condyloid, 
and  articulates  with  the  temporal  bone.  This  process  has  a  neck 
which  receives  the  insertion  of  the  external  pterygoid  muscle. 

The  Coronoid  Process  is  thin,  flat,  and  triangular.  To  its  external 
surface  is  attached  the  temporal  and  masseter  muscles.  On  its  internal 
surface  is  a  longitudinal  ridge  extending  to  the  posterior  jjart  of  the 
alveolar  process,  and  to  which  is  attached  the  temporal  muscle  above 
and  the  buccinator  muscle  below.  In  front  of  this  ridge  is  a  deep 
groove,  to  which  the  temporal  and  buccinator  muscles  are  in  part 
attached. 

The  Condyloid  Process  consists  of  two  portions — a  condyle  and  a 
neck.  The  condyle  is  of  an  oval  form,  convex  both  laterally  and  from 
before  backward.  The  neck  of  the  condyle,  flattened  from  before 
backward,  convex  on  its  posterior  surface,  presents  anteriorly  a  depres- 
sion, the  pterygoid  fossa,  for  the  attachment  of  the  external  pterygoid 
muscle.  Between  these  two  j)rocesses  is  the  sigmoid  notch,  a  semilunar 
depression  over  which  passes  the  masseteric  artery  and  nerve. 

The  structure  of  the  inferior  maxilla  is  compact  externally,  cellular 
within,  and  is  travei'sed  the  greater  part  of  its  extent  by  the  inferior 
dental  canal. 

The  lower  jaw  is  developed  from  two  centres  of  ossification,  which 
meet  at  the  symphysis.  It  articulates  on  each  side,  by  one  of  its  con- 
dyles, with  the  glenoid  cavity  of  the  temporal  bone,  situated  at  the  base 


68 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


of  the  zygomatic  process.  This  cavity  is  divided  into  two  portions — 
an  anterior  and  a  posterior.  The  former  constitutes  the  articular  por- 
tion, the  latter  lodges  a  process  of  the  parotid  gland.  The  two  are 
separated  by  the  fissure  of  Glasserius,  which  transmits  the  chorda 
tympani  nerve,  the  laxator  tympani  muscle,  and  the  anterior  tympanic 
artery.  It  also  gives  lodgment  to  the  long  process,  processus  gracilis, 
of  the  malleus. 

Between  this  cavity  and  the  condyle  there  is  interposed  an  inter- 
articular  cartilage,  so  moulded  as  to  fit  the  two  articular  surfaces. 
The  circumference  of  this  being  free,  except  where  it  adheres  to  the 
external  lateral  ligament,  affords  attachment  to  a  few  fibres  of  the  ex- 
ternal pterygoid  muscle,  and  facilitates  the  movements  of  the  joint. 

Fig.  11. 


UlAXILLA/tr 


SUPERIOR  MEATUS 
9PKH0     PALfTIME   r  OK  AMEN 


HORIZONTAL      PLATE 

The  union  of  this  articulation  is  maintained  by  the  external  lateral, 
the  spheno-maxillary,  and  the  stylo-maxillary  ligaments. 


THE   PALATE   BONES. 


The  Palate  Bones,  two  in  number,  are  situated  at  the  back  part  of 
the  superior  maxillary  bone,  between  its  tuberosities  and  the  pterygoid 
processes  of  the  sphenoid  bone. 

The  palate  bone  is  divided  into  two  plates  :  the  inferior  or  horizontal, 
and  the  superior  or  vertical. 

The  horizontal i^late  is  broad  and  on  the  same  line  with  the  palate  pro- 
cesses of  the  superior  maxillary  bone;  its  upper  surface  is  smooth  and 
forms  the  posterior  floor  of  the  nostrils ;  the  lower  surface  is  rough  and 


THE   PALATE    BONES. 


69 


forms  the  posterior  part  of  the  roof  of  the  mouth ;  its  anterior  edge  is 
connected  with  the  palate  process  of  the  upper  jaw,  and  its  posterior  is 
thin  and  crescentic,  to  which  is  attached  the  velum-pendulum  palati, 
or  soft  palate ;  at  the  posterior  point  of  the  suture,  uniting  the  two 
palate  bones,  there  projects  backward  a  process  called  the  posterior 
nasal  spine,  which  gives  origin  to  the  azygos-uvulse  muscle.  The  ver- 
tical plate  ascends,  helps  to  bound  the  nasal  cavity,  diminishes  the 
opening  into  the  antrum  by  projecting  forward,  and  by  its  external 
posterior  part,  in  conjunction  with  the  pterygoid  processes  of  the 
sphenoid  bone,  forms  the  posterior  palatine  canal;  the  lower  orifice  of 
which  is  seen  on  the  margin  of  the  palate  plate,  and  is  called  the  pos- 
terior palatine  foramen,  transmitting  the  palatine  nerve  and  artery  to 
the  soft  palate ;  behind  this  foramen  is  often  seen  a  smaller  one,  passing 
through  the  base  of  the  pterygoid  process  of  this  bone,  and  sending  a 
filament  of  the  same  nerve  to  the  palate. 

The  upper  end  of  the  vertical  or  nasal  plate  has  two  processes — the  one 
is  seen  at  the  back  of  the  orbit,  called  the  orbital  process ;  the  other  is 
posterior,  and  fits  against  the  under  surface  of  the  body  of  the  sphenoid 
bone.  Between  these  two  processes  is  a  foramen,  the  spheno-palatine, 
which  transmits  to  the  nose  a  nerve  and  artery  of  the  same  name. 

The  palate  bone  articulates  with  six  others,  namely :  the  superior 
maxillary,  inferior  turbinated, 
vomer,  sphenoid,  ethmoid  and 
opposite  palate. 

The  structure  of  this  bone  is 
very  thin,  and  consists  almost 
entirely  of  compact  tissue.    Its 
development,  it  is  said,  takes  < 
place  by  a  single  point  of  ossi-  tj 
fication    at   the   union    of  the  - 
vertical,  horizontal  and  pyra-  ^ 
midal  portions. 

The  bones  of  the  head  are  "^ 
twenty-two  in  number,  of  which  ^ 
eight  compose  the  cranium  and 
fourteen  the  face.  Those  of 
the  cranium  are  one  frontal, 
two  parietal,  two  temporal,  one 
occipital,  one  sphenoid,  and  one 
ethmoid.    Those  of  the  face  are 

six  pairs  and  two  single  bones ;  the  pairs  are  the  two  malar,  two  superior 
maxillary,  two  lachrymal,  two  nasal,  two  palatine  and  two  inferior  tur- 
binated.    The  vomer  and  inferior  maxillary  are  the  two  single  bones. 


Fig.  12. 


SPHENO.P/ILA  TtflE  FOR  A. 


SPHENOIDAL    PROCESS 

AflTICULAn  PORT. 


NOt\l AfirfCULAR  po/ir. 


70  PEINCIPLES   AND   PRACTICE   OF   DENTISTRY, 


CHAPTER  V. 

MUSCLES. 

MUSCLES  are  the  fleshy  parts  of  the  body.     They  are  the  active 
organs  of  locomotion,  and  are  composed  of  fibres  bound  together 
in  bundles  or  fasciculi,  by  delicate  areolar  tissue. 

The  muscular  fibres  of  which  each  muscle  is  compounded  are  called 
ultimate  fibres.  Of  these  anatomists  recognize  two  kinds — voluntary 
or  animal  fibres  (striped),  and  involuntary  or  organic  fibres  (unstriped). 
The  former  are  generally  under  the  influence  of  the  will,  are  of  uniform 
size,  and  present  transverse  markings.  They  compose  the  muscles  of 
the  trunk  and  limbs,  as  well  as  those  of  the  heart,  urethra,  internal 
ear,  and,  in  part,  those  of  the  oesophagus  ;  though  the  muscles  of  the 
heart  are  striped,  they  are  not  voluntary ;  the  muscular  coat  of  the 
urethra  consists  of  two  layers  of  plain,  muscular  fibre ;  the  muscles  of 
the  internal  ear  are  striped,  but  are  not  voluntary ;  in  the  upper  part 
of  the  oesophagus  the  muscular  fibres  consist  chiefly  of  the  striped 
variety,  but  below  they  consist  entirely  of  the  involuntary  or  unstriped 
muscular  fibre. 

The  involuntary  fibres  are  not  under  volitional  control,  are  not 
striped,  are  of  smaller  size  and  homogeneous  structure.  Thev  are 
found  in  the  digestive  canal,  uterus  and  bladder.  The  voluntary 
muscles  terminate  in  fibrous  tissue,  which  is  sometimes  gathered  to- 
gether in  bundles  to  form  tendon,  or  is  spread  out  in  a  membranous 
f()rm,  and  is  then  called  aponeurosis.  By  one  or  the  other  of  these 
terminal  forms  almost  all  muscles  are  attached  to  those  parts  which 
it  is  their  office  to  move. 

The  involuntary  muscles  are  generally  found  intei'lacing  freely 
around  a  cavity,  which,  by  their  contraction,  they  constrict,  expelling 
its  contents.  Each  muscle  is  closely  though  loosely  invested  by  a 
sheath  of  cellular  tissue,  which  also  sends  prolongations  into  the  body 
of  the  muscle,  investing  each  fibre  and  binding  them  together.  Muscles 
are  variously  named,  according  to  their  form,  long,  broad,  short,  etc. 
These  names  sufiiciently  explain  themselves.  Other  names  are  given 
them,  dejiending  on  the  arrangement  of  their  fibres,  their  situation, 
number  of  divisions,  office,  etc. ;  for  fuller  explanation,  students  ai-e 
referred  to  more  exclusively  anatomical  works. 

The  Fascia,  which  everywhere  invests  the  more  delicate  organs,  is 
of  two  kinds — superficial  or  fibro-areolar,  and  deep  or  aponeurotic. 


MUSCLES.  71 

The  superficial  fascia  lies  just  beneath  the  skin,  and  covers  nearly  the 
entire  surface  of  the  body.  It  serves  to  connect  the  skin  with  the 
deep  fascia,  and  furnishes  a  nidus  for  nerves  and  blood  vessels  passing 
to  the  skin. 

The  deep  fascia  is  composed  of  fibres  arranged  in  a  reticulated 
manner,  forming  a  dense,  inelastic  membrane,  which  invests  each 
muscle  in  a  separate  sheath.  Sheaths  are  also  formed  from  it  for 
the  vessels  and  nerves;  and  it  serves  also  as  points  of  attachment 
for  the  muscles. 

Each  striped  muscular  fibre  is  composed  of  two  parts  —a  proper 
substance  called  the  sarcous  element,  in  which  the  contractile  property 
resides,  and  a  sheath  or  sarcolemma,  a  transparent,  structureless  mem- 
brane, in  which  is  contained  the  contractile  substance.  These  element- 
ary fibres  are  connected  by  areolar  tissue,  with  which  a  little  fat  is 
often  associated.  Lying  between  these  fibres  are  blood  vessels,  nerves, 
and  lymphatics. 

The  sarcous  element  is  a  soft,  granular  material,  on  the  varying 
relations  of  which  granules  to  each  other  depend  the  alterations 
in  a^apearance  of  the  striae.  If  they  approach  each  other  more 
closely  in  the  direction  of  the  length  of  the  fibre  than  in  its  width, 
it  will  appear  fibrillated ;  if  the  reverse,  it  will  present  the  appear- 
ance of  discs. 

Muscles,  like  all  other  tissues,  are  developed  from  germinal  matter 
which  has  undergone  special  metamorphosis,  under  the  impulse  of  the 
parent  cell,  to  construct  this  tissue.  "  Germinal  matter"  and  "formed 
material "  constitute  the  "  elementary  part," — according  to  Mr.  Beale 
— or  the  muscular  cell  of  other  writers  from  which  the  muscular  fibre 
is  formed.  In  the  formed  material,  which  is  the  constructed  muscle, 
resides  the  power  of  contraction.  The  germinal  matter  or  constructive 
part  does  not  possess  this  property. 

Following  the  arrangement  of  Mr.  Gray,  we  shall  divide  the  muscles 
which  it  is  our  jDurpose  to  describe  into  certain  groups,  as  follows : — 

1.  Nasal  Group.  2.  Superior  Maxillary  Group. 

Pyramidalis  Nasi.  Levator  Labii  Superioris  Proprius. 

Levator  Labii  Superioris  Alseque  Nasi.  Levator  Anguli  Oris. 
Levator  Proprius  Alae  Nasi  Posterior.     Zygomaticus  Major. 
Levator  Proprius  Alse  Nasi  Anterior.      Zj^goraaticus  Minor. 
Compressor  Naris. 

Compressor  Narium  Minor.  3.  Inferior  Maxillary  Group. 

Depressor  Alse  Nasi.  Levator  Labii  Tnferioris. 

Depressor  Labii  Inferioris. 

Depressor  Anguli  Oris. 


72  PRINCIPLES   AXD   PRACTICE   OF   DENTISTRY. 

4.  Temporo-Maxillary  Group.  7.  Pharyngeal  Group. 

Masseter.  Constrictor  Inferior. 

Temporal.  Constrictor  Medius. 

c     T,  TT  ,-,  Constrictor  Superior. 

5.  Fterygo-Maxillary  Group.  o    ,       , 

otylo-pharyDgeus. 
Pterygoideus  Externus.  Palato-pharyngeus. 

Pterygoideus  Internus. 

8.  Palatal  Group. 
6.  Lingual  Group.  ^       ,      -r.  ,    . 

Levator  ralati. 
Genio-hyo-glossus.  Tensor  p^l^^i. 

Hyo-glossus.  ^^ygos  Uvulae. 

Lingualis.  Palato-glossus. 

Stylo-glossus.  Palato-pharyngeus. 

Palato-glossus. 

1.  Nasal  Group. 

Pyramidalis  Nasi. 

Levator  Labii  Superioris  Alseque  Nasi. 

Levator  Proprius  Alse  Nasi  Posterior. 

Levator  Proprius  Alae  Nasi  Anterior. 

Compressor  Naris. 

Compressor  Narium  Minor. 

Depressor  Alae  Nasi. 

'v 

The  Pyramidalis  Nasi  is  a  triangular,  muscular  slip  extended  from 
the  occipito  frontalis.  It  lies  along  the  side  of  the  nose,  and  blends  by 
a  tendinous  expansion  with  the  compressor  naris. 

The  Levator  Labii  Superioris  Alceque  Nasi  is  also  a  triangular 
muscle,  arising  from  the  nasal  process  of  the  superior  maxilla,  its 
upper  part.  Passing  down  behind  the  muscle  just  described,  it  divides 
into  two  muscular  slips,  one  of  which  is  inserted  into  the  cartilage  of 
the  ala  of  the  nose,  the  other  is  continued  to  the  angle  of  the  mouth, 
where  it  blends  with  the  orbicularis  oris  and  levator  labii  proprius. 

Beneath  this  muscle  is  a  small  muscular  slip  extending  from  the 
origin  of  the  compressor  naris  to  the  nasal  process,  about  an  inch  above 
it.     It  is  called  the  "  Musculus  Anomalus,"  or  the  "  Rhoraboideus." 

The  Levator  Proprius  Alee  Nasi  Posterior,  or  Dilator  Naris  Posterior, 
extends  from  the  nasal  notch  to  the  margin  of  the  nostril. 

The  Levator  Proprius  Aloe  Nasi  Anterior,  or  the  Dilator  Naris 
Anterior,  is  situated  a  little  in  front  of  the  last  described  muscle,  and 
arises  from  the  cartilage  of  the  wing  of  the  nose,  and  is  inserted  into 
the  integument  near  its  margin. 

The  Compressor  Naris,  triangular  in  form,  arises  from  the  superior 
maxilla,  a  little  above  and  external  to  the  incisive  fossa,  and  is  attached 
to  the  fibro-cartilage  of  the  nose,  joining  at  the  median  line  with  its 
fellow  of  the  opposite  side. 


MUSCLES.  73 

The  Compressor  Narium  Minor  extends  from  the  alar  cartilage  to 
the  integumeut  of  the  end  of  the  nose. 

The  Depressor  Aloe.  Nasi  arises  from  the  incisive  fossa  of  the  superior 
maxilla,  and,  dividing  into  two  sets  of  fibres,  ascending  and  descending, 
is  inserted  into  the  septum  and  posterior  portion  of  nasal  cartilage, 
and  by  some  fibres  of  the  latter  into  the  back  part  of  the  orbicularis 
oris. 

The  facial  nerve  supplies  all  the  muscles  of  this  group. 

Their  respective  actions  are  sufficiently  explained  by  their  names, 
except  the  pyramidalis,  which  draws  down  the  inner  angle  of  the  eye- 
brow, and  perhaps  aids  in  dilating  the  nostril,  and  the  compressores 
nasi,  whose  action  is  directly  opposite  to  that  implied  by  their  names. 

The  contraction  of  the  levator  labii  superioris  alreque  nasi  gives  to 
the  face  the  expression  of  contempt. 

2.  Superior  Maxillary  Group. 

Levator  Labii  Superioris  Proprius. 
Levator  Auguli  Oris. 
Zj^gomaticus  Major. 
Zygomaticus  Minor. 

The  Levator  Labii  Siqoerioris  Proprius  arises  from  the  lower  margin 
of  the  orbit,  some  of  its  fibres  from  the  superior  maxillary,  others  from 
the  malar  bone ;  they  pass  down  to  be  inserted  in  the  fleshy  part  of  the 
upper  lip. 

The  Levator  Angidi  Oris  arises  from  the  canine  fossa,  just  below  the 
infra-orbital  foramen,  and  descends  to  the  angle  of  the  mouth,  where 
it  blends  with  the  orbicularis  oris,  the  zygomatici  and  the  depressor 
anguli  oris  muscles. 

The  Zygomaticus  Major  is  a  delicate  fasciculus,  arising  from  the 
malar  bone,  and  finding  attachment  to  the  orbicularis  and  depressor 
anguli  oris  at  the  angle  of  the  mouth. 

The  Zygomaticus  Minor  arises  from  the  malar  bone,  just  behind  the 
maxillary  suture,  and  passes  downward  and  inward,  to  be  inserted  in 
the  outer  margin  of  the  levator  labii  superioris,  with  which  it  is  con- 
tinuous. 

These  muscles  are  also  supplied  by  the  facial  nerve. 

The  action  of  the  levator  muscles  is  described  in  their  names.  The 
zygomatici  draw  the  lip  upward  and  outward,  as  in  laughing. 

3.  Inferior  Maxillary  Group. 

Levator  Labii  Inferioris.  (Levator  Menti.) 

Depressor  Labii  Inferioris.  (Qnadratus  Menti.) 

Depressor  Anguli  Oris.  (Triangularis  Menti.) 


74 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


The  Levator  Labii  Inferioris  arises  from  the  incisive  fossa  just  exter- 
nal to  the  symphysis  of  the  chin ;  it  is  a  small,  conoidal  fasciculus,  and 
is  inserted  into  the  integument  of  the  chin. 

The  Depressor  Labii  Inferioris  is  a  quadrilateral  muscle,  arising  from 
the  oblique  line  of  the  inferior  maxilla,  between  the  incisive  fossa  and 
mental  foramen,  and  is  attached  to  the  integument  of  the  lower  lip, 
blending  with  the  orbicularis  oris  and  with  its  fellow  of  the  opposite  side. 

The  Depressor  Anguli  Oris,  situated  externally  to  the  last-mentioned 
muscle,  also  arises  from  the  external  oblique  line  of  the  low'er  jaw,  and 
is  attached  at  the  angle  of  the  mouth  to  the  orbicularis,  levator  anguli 
and  zygomaticus  major  muscles. 

The  facial  nerve  supplies  this  group. 

Their  action  is  indicated  by  their  names. 

Fig.  13. 


4.  Temporo-Maxillary  Group. 

Temporal. 
Masseter. 

The  Temporal  Muscle  (Fig.  13)  is  seen  on  the  side  of  the  head.  It  has 
its  origin  from  the  serai-circular  ridge,  commencing  at  the  external 
angular  process  of  the  os-frontis,  and  extending  along  this  and  the 
parietal  bone ;  also  from  the  surfaces  below^  this  ridge  formed  by  the 
frontal  and  squamous  portion  of  the  temporal  and  sphenoid  bones ; 


MUSCLES. 


75 


likewise  from  the  under  surface  of  the  temporal  aponeurosis,  and  from 
a  fascia  covering  this  muscle;  and  its  fibres  are  inserted,  after  they 
have  converged  and  passed  under  the  zygoma,  into  the  coronoid  pro- 
cess of  the  lower  jaw,  surrounding  it  on  every  side  by  a  dense,  strong 
tendon. 

Fic.  14. 


£;     =^kji\     \'  \ 


The  Masseter  Muscle  (Fig.  14)  is  seen  at  the  side  and  back  part  of 
the  face,  in  front  of  the  meatus  externus,  and  lies  directly  under  the 
skin.  It  arises  by  two  portions  :  the  one  anterior  and  tendinous,  from 
the  superior  maxilla  where  it  joins  the  malar  bone  ;  the  other  portion, 
mostly  fleshy,  from  the  inferior  edge  of  the  malar  bone  and  the  zygo- 
matic arch  as  far  back  as  the  glenoid  cavity,  and  is  inserted,  tendinous 


76 


PEIXCIPLES    AND    PRACTICE    OF    DENTISTRY. 


and  fleshy,  into  the  external  side  of  the  ramus  of  the  jaw  and  its  angle 
as  far  up  as  the  coronoid  process. 

The  inferior  maxillary  nerve  supplies  both  these  muscles. 

The  oflSce  of  the  temporal  muscle  is  to  bring  the  two  jaws  together, 
as  in  the  cutting  and  rending  of  the  food. 

The  use  of  the  masseter  muscle,  when  both  portions  act  together,  is 
to  close  the  jaws  ;  if  the  anterior  acts  alone,  the  jaw  is  brought  forward, 
if  the  posterior,  it  is  drawn  backward. 

The  use  of  the  pterygoid  muscle  is  to  aid  the  temporal  and  masseter 
muscles  in  the  trituration  of  the  food.     The  external  pterygoids  carry 

Fig.  15. 


the  lower  jaw  directly  forward  when  acting  together,  to  one  or  the 
other  side  when  acting  separately.  The  internal  pterygoid  aids  the 
masseter  and  temporal  in  bringing  the  lower  jaw  firmly  up  against  the 
superior  maxilla,  and  also  assists  in  carrying  the  lower  jaw  forward. 

The  inferior  maxillary  nerve  supplies  these  muscles,  which  form  the 
pterygo-maxillary  group,  and  which  come  next  in  order  of  desci'iption. 

5.  Pteeygo-Maxillary  Group. 

Pterygoideus  Externus. 
Pterygoideus  Interims. 

Pterygoideus  Externus  (Fig.  15)  arises  from  the  outer  surface  of  the 
external  plate  of  the  pterygoid  process  of  the  sphenoid  bone,  from  the 
tuberosity  of  the  superior  maxilla,  and  from  the  ridge  on  the  sphenoid 


MUSCLES. 


77 


bone  separating  the  zygomatic  from  the  pterygoid  fossa,  and  is  inserted 
into  the  inner  side  of  the  neck  of  the  lower  jaw,  and  capsular  ligament 
of  the  articulation. 

Pterygoideus  Internum  arises,  tendinous  and  fleshy,  from  the  inner 
surface  of  the  pterygoid  plate,  fills  the  greater  jDart  of  the  pterygoid 
fossa,  and  is  inserted,  tendinous  and  fleshy,  into  the  inner  face  of  the 
angle  of  the  inferior  maxilla  and  the  rough  surface  above  the  angle. 

The  external  one  is  triangular,  having  its  base  at  the  pterygoid  pro- 

FiG.  16. 


cess  and  running  outward  and  backward  to  the  neck  of  the  condyle. 
The  internal  is  strong  and  thick,  placed  on  the  inside  of  the  ramus  of 
the  jaw,  and  running  downward  and  backward  to  the  angle. 

6.  Lingual  Group. 
Genio-hyo-glossus. 
Hyo-glossus. 
Lingualis. 
Stylo-glossus. 
Palato-glossus. 
The  Genio-hyo-glossus  (Fig.  16)  is  attached,  as  its  name  implies,  to 


PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


the  chin,  hyoid  bone,  and  tongue.  It  is  a  triangular,  fan-like  muscle, 
arising  by  its  apex  from  the  superior  genial  tubercle,  and  has  its 
inferior  fibres  running  parallel  with  the  genio-hyoid  to  be  inserted 
into  the  hyoid  bone,  while  its  middle  and  anterior  fibres  are  inserted 
into  the  under  surface  of  the  tongue  its  whole  length. 

The  Hyo-glossus,  a  thin,  broad,  quadrilateral  muscle,  has  its  origin 
from  the  body,  cornu,  and  appendix,  of  the  os-hyoides,  and  is  inserted 
into  the  side  of  the  tongue,  forming  the  greater  part  of  its  bulk. 

The  Lingualis  has  its  origin  on  the  under  surface  of  the  tongue,  ex- 
tending from  its  base  and  the  hyoid  bone  to  the  apex,  and  so  inter- 
mingling with  the  other  muscles  as  to  be  considered  rather  a  part  of 
them  than  a  distinct  muscle. 

The  Stylo-glossus  arises  from  the  point  of  the  styloid  process  and 
stylo-maxillary  ligament.  It  is  inserted  into  the  side  of  the  tongue 
•near  its  root,  its  fibres  running  to  the  tip. 

The  Palato-glossus  is  more  directly  associated  with  the  soft  palate, 
and  will  consequently  be  described  with  the  palatal  group. 


Fifj.  17. 


7.  Pharyngeal  Group. 
Constrictor  Inferior. 
Constrictor  Medius. 
Constrictor  Superior. 
Stylo-pharyngeus. 
Palato-pharyngeus. 

The  Inferior  Constrictor  of 
the  pharynx  (Fig.  17)  arises 
from  the  side  of  the  thyroid 
cartilage  and  its  inferior  cornu, 
and  from  the  side  of  the  cricoid 
cartilage,  and  is  inserted  with 
its  fellow  into  the  middle  line 
on  the  back  of  the  pharynx. 
This  is  the  largest  of  the  con- 
strictor muscles,  and  overlaps 
the  middle  constrictor. 

The  Middle  Constrictor  of  the 
pharynx  (Fig.  17)  arises  from 
the  appendix  and  both  coruua 
of  the  os-hyoides,  and  from  the 
thyro-hyoid  ligament;  its  fibres 
ascend,  run  transversely  and 
descend,  giving  a  triangular 
appearance ;  the  upper  ones 
overlap  the  superior  constrictor, 


MUSCLES.  79 

while  the  lower  are  beneath  the  inferior ;  the  whole  pass  back  to  be 
inserted  into  the  middle  tendinous  line  of  the  pharynx. 

The  Superior  Comtridor  (Fig.  17)  arises  from  the  cuneiform  process 
of  the  occipital  bone,  from  the  lower  part  of  the  internal  pterygoid 
plate  of  the  sphenoid  bone,  from  the  pterygo-maxillary  ligament,  and 
from  the  posterior  third  of  the  mylo-hyoid  ridge  of  the  lower  jaw, 
near  the  root  of  the  last  molar  tooth.  It  is  inserted  with  its  fellow 
into  the  middle  tendinous  line  at  the  back  of  the  pharynx. 

The  Stylo-pharyngeus  arises  from  the  root  of  the  styloid  process, 
and  is  inserted  into  the  side  of  the  pharynx  and  corner  of  the  os- 
hyoides  and  thyroid  cartilage.  It  is  a  long  and  narrow  muscle,  and 
passes  to  the  pharynx  between  the  uj^per  and  middle  constrictors. 

The  Palato-j^haryngeiis,  which  forms  the  posterior  pillar  of  the 
soft  palate,  is  a  long,  fleshy  muscle,  wider  at  either  extremity  than  in 
the  middle,  and  arises  from  the  soft  palate  by  a  divided  fasciculus, 
between  which  points  of  attachment  lies  the  levator-palati.  It  j)asses 
behind  the  tonsil,  downward  and  outward,  to  be  inserted  into  the 
posterior  part  of  the  thyroid  cartilage,  together  with  the  stylo- 
pharyngeus. 

The  muscles  of  this  group  are  supplied  with  nerves  from  the  pharyn- 
geal plexus  and  glosso-pharyngeal  nerve ;  an  additional  branch  from 
the  external  laryngeal  nerve  being  sent  to  the  inferior  constrictor ; 
the  palato-pharyngeus  i-eceives  a  branch  from  Meckel's  ganglion. 

These  muscles  are  exercised  in  the  act  of  deglutition,  and  also  exert 
an  influence  in  modulating  the  voice. 

8.  Palatal  Group, 

The  Levator  Palati, 

The  Tensor,  or  Circumflexus  Palati. 

Constrictor  Isthmi-fauciura,  or  Palato-glossus. 

Palato-pharyngeus. 

Azygos-uvulse. 

The  Levator  Palati  (Fig,  18)  arises  from  the  point  of  the  petrous 
portion  of  the  temporal  bone  and  adjoining  portion  of  the  Eustachian 
tube,  descends,  and  is  inserted  into  the  soft  palate. 

The  Tensor,  or  Circumflexus  Palati,  arises  from  the  base  of  the 
pterygoid  process  of  the  sphenoid  bone  and  from  the  Eustachian  tube ; 
it  descends  in  contact  with  the  internal  pterygoid  muscle  to  the  hamu- 
lus, round  which  it  winds,  and  is  inserted  into  the  soft  palate,  where  it 
expands  and  joins  its  fellow. 

The  Constrictor  Isthmi-faucium,  or  Palato-glossus,  occupies  the  ante- 
rior lateral  half  arches  of  the  palate ;  it  arises  from  the  side  of  the 
tongue  near  its  root,  and  is  inserted  into  the  velum  near  the  uvula. 


80 


PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


The  Palato-pharyngeus  has  already  been  described  with  the  muscles 
of  the  pharyngeal  group. 

The  Azygos-uvulcB  arises  from  the  posterior  spine  of  the  palate  bones 
at  the  termination  of  the  palate  suture,  runs  along  the  central  line  of 
the  soft  palate,  and  ends  in  the  point  of  the  uvula.  It  raises  and 
shortens  the  uvula. 

It  is  thus  seen  that  the  various  muscles  of  the  soft  palate  are  all 
concerned,  more  or  less,  in  conducting  the  food  into  the  pharyngeal 

Fig.  18. 


cavity.  The  elevators  raise  the  palate,  and  at  the  same  time  protect 
the  posterior  nares  from  regurgitation  of  the  food ;  while  the  tensor 
puts  it  on  the  stretch,  and  after  it  has  passed  the  velum,  the  con- 
strictor isthmi  faucium  and  palato-pharyngeus  draw  the  palate  down, 
and  thus  close  the  opening  into  the  mouth  ;  after  which  the  food,  as 
already  mentioned,  is  grasped  by  the  constrictor  muscles  of  the 
pharynx,  and  conveyed  into  the  oesophagus. 


MUSCLES.  81 

The  Soft  Palate  is  a  movable  curtain,  composed  of  mucous  mein- 
braue,  inclosing  several  muscles.  It  is  situated  at  the  back  part  of  the 
mouth  between  this  cavity  and  the  pharynx,  is  connected  above  to  the 
posterior  edge  of  the  hard  palate,  and  laterally  to  the  side  of  the 
tongue  and  pharynx. 

By  this  arrangement,  the  soft  palate  has  the  appearance  of  a  lunated 
or  arched  veil  between  the  cavity  of  the  mouth  and  the  pharynx. 

In  the  centre  of  this  arch  an  oblong  body  is  suspended,  called  the 
uvula,  which  divides  the  soft  palate  into  lateral  half  arches,  that  pass 
on  either  side  from  the  uvula  to  the  root  of  the  tongue. 

There  is  also  seen  passing  from  the  uvula  on  each  side  to  the 
pharynx,  two  other  arches,  which,  from  being  behind  the  first,  are 
called  the  posterior  arches  or  pillars. 

Between  the  anterior  and  posterior  pillars,  on  either  side,  is  a  trian- 
gular interval  containing  the  tonsil  glands. 

The  Fauces  are  the  straits  or  passage  leading  from  the  mouth  to  the 
pharynx ;  and  the  space  included  between  the  soft  palate  above,  the 
half  arches  or  tonsils  on  either  side,  and  the  root  of  the  tongue  below, 
is  called  the  isthmus  of  the  fauces. 

The  Tonsils  are  two  bodies,  each  about  the  size  of  an  almond,  seen 
at  the  root  of  the  tongue  on  its  sides,  occupying  the  cavity  between 
the  anterior  and  posterior  half  arches.  They  consist  of  a  group  of 
compound  follicular  glands,  forming  somewhat  oval  bodies,  whose  en- 
largement constitutes  an  obstacle  to  deglutition,  and  by  their  locality 
near  the  mouths  of  the  Eustachian  tubes,  frequently  cause  obstruction 
and  deafness. 

ARTICULATIONS. 

Articulation  is  a  term  used  in  Anatomy  to  denote  the  various  modes 
of  union  between  the  bones  of  the  skeleton.  Articulations  are  classed 
under  three  general  heads,  namely — movable  joints,  immovable  joints, 
and  joints  of  a  mixed  order,  the  latter  being  somewhat  movable 
without  much  relative  displacement  of  the  contiguous  surfaces.  The 
lower  jaw  is  an  example  of  a  movable  articulation  which  is  known 
as  the — 

Temporo-maxillary  Articulation. — The  inferior  maxillary  bone  articu- 
lates with  the  anterior  portion  of  the  glenoid  cavitj^  of  the  temporal 
bone,  forming  the  temporo-maxillary  articulation.  This  joint  consists 
of  the  convex  condyloid  head  or  process  of  the  inferior  maxillary 
bone,  the  concave  surface  of  the  glenoid  fossa,  the  iuterarticular 
fibro-cartilage,  a  double  synovial  membrane,  and  a  loose  capsular 
ligament. 

The  Capsular  Ligament  is  a  very  loose  sac,  attached  above  to  the 
circumference  of  the  glenoid  cavity,  and  in  front  to  the  articular  root 
6 


82  PRINCIPLES    AND    PRACTICE   OF    DENTISTRY. 

of  the  zygoma ;  below  it  embraces  the  neck  of  the  inferior  maxillary- 
bone,  immediately  below  the  head  or  condyloid  process. 

The  Interarticular  Fibro-eartilage  is  an  ovoid  plate  placed  between 
the  bones,  and  is  supported  in  position  by  a  circumferential  attach- 
ment to  the  common  capsule,  the  external  lateral  ligament,  and  to  the 
tendon  of  the  external  pterygoid  muscle.  Below  its  face  is  concave, 
corresponding  with  the  convexity  of  the  condyle ;  above  it  is  concave 
in  front  and  convex  behind,  corresponding  with  the  glenoid  cavity 
proper  and  the  articular  eminence.  The  composition  of  the  circum- 
ference is  fibrous  with  a  cartilaginous  centre,  being  frequently  quite 
soft  and  sometimes  perforated. 

The  Synovial  Membranes,  one  above  and  the  other  below  the  inter- 
articular fibro-cartilage,  are  the  lubricating  membranes,  and  in  form 
are  similar  to  two  small  sacs.  They  secrete  the  synovia,  a  fluid  which 
.  resembles  the  white  of  an  egg,  but  which  is  more  oily  and  resistive  in 
its  nature. 

The  Internal  Lateral  Ligament  descends  from  the  spinous  process  of 
the  great  wing  of  the  sphenoid  bone,  and  is  attached  to  the  inner  sur- 
face of  the  ramus. 

The  Stylo-maxillary  Ligament  passes  behind  from  the  styloid  process 
of  the  temporal  bone  to  be  inserted  just  above  the  angle. 

The  External  Lateral  Ligament  has  its  origin  from  the  zygoma,  and 
passes  obliquely  downward  and  backward  to  be  inserted  about  the 
neck  of  the  condyle ;  it  is  a  short,  somewhat  triangular-shaped  band 
of  fibrous  tissue,  and  assists  in  forming  the  common  capsule.  Exter- 
nally it  is  very  superficial,  being  covered  only  by  the  integuments, 
except  in  cases  whpre  the  parotid  gland  overlaps  it. 


CHAPTER   VI. 

BLOOD   VESSELS   OF   THE   MOUTH. 

THE  arteries  that  supply  the  mouth  come  from  the  external  carotid. 
This  is  a  division  of  the  common  carotid  which  arises  on  the  right 
side  from  the  arteria  innominata,  and  on  the  left  from  the  arch  of  the 
aorta  ;  after  passing  uj)  the  neck  on  either  side,  along  the  course  of  the 
sterno-cleido-mastoid  muscles,  it  divides,  on  a  level  with  the  top  of  the 
thyroid  cartilage,  into  its  two  great  branches — the  external  and  in- 
ternal carotid  arteries. 

The  Internal  Carotid  Artery  has  a  tortuous  course ;  is  first  to  the 


BLOOD   VESSELS   OF  THE    MOUTH. 


83 


outside  and  behind  the  external  carotid ;  then  ascends  in  front  of  the 
vertebral  column  by  the  side  of  the  pharynx  and  behind  the  digastric 
and  styloid  muscles  to  the  carotid  foramen  in  the  petrous  portion  of 
the  temporal  bone ;  thence  it  traverses  the  canal  in  this  bone  and 
enters  the  brain,  supplying  it  with  most  of  its  vessels,  not  giving  any 
to  the  mouth. 

The  External  Carotid  extends  from  the  top  of  the  larynx  to  the 
neck  of  the  condyle  of  the  lower  jaw ;  at  first  anterior  and  on  the 
inside  of  the  internal  carotid,  it  soon  gets  to  the  outside,  then  passes 
under  the  digastric  and  stylo-hyoid  muscles  and  lingual  nerve,  becomes 

Fig.  19. 


imbedded  in  the  parotid  gland,  and  terminates  between  the  neck  of 
the  inferior  maxilla  and  the  auditory  meatus  in  the  temporal  and  in- 
ternal maxillary  arteries. 

The  branches  of  the  external  carotid  with  which  we  have  to  do 
are  the 

Lingual.. 

Facial. 

Ascending  Pharyngeal. 

Temporal. 

Internal  Maxillary. 


84  PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 

The  Lingual  Artery  arises  from  the  external  carotid,  betNS'een  the 
superior  thyroid  and  facial ;  passing  obliquely  up  to  the  great  corner 
of  the  hyoid  bone,  it  runs  parallel  with,  and  ascending  perpendicularly 
to  the  base  of  the  tongue,  continues  its  course  to  the  tip  of  that  organ, 
under  the  name  of  the  ranine  artery.  This  part  of  the  artery  lies  just 
beneath  the  mucous  membrane,  and  is  in  danger  of  being  wounded  in 
division  of  the  freenum  in  children.  This  accident  may  be  avoided  by 
using  blunt-pointed  scissors,  and  directing  the  points  downward  and 
backward. 

The  hypo-glossal  nerve  accompanies  this  artery. 

The  branches  of  the  lingual  artery  with  which  we  are  concerned 
are  the 

Dorsalis  Linguae. 

Sublingual. 

Ranine. 

The  Dorsalis  Linguce  arises  from  the  lingual  artery,  beneath  the 
hyo-glossus  muscle,  and  is  distributed  to  the  tonsil,  epiglottis,  soft  palate 
and  mucous  membrane  of  the  tongue. 

The  Sublingual  arises  from  the  lingual  at  the  point  of  bifurcation, 
near  the  anterior  margin  of  the  hyo-glossus  muscle,  and  passes  forward 
to  be  distributed  to  the  sublingual  gland,  to  the  mucous  membrane  of 
the  mouth  and  gums,  and  to  the  neighboring  muscles. 

The  Ranine  may  be  considered  the  continuation  of  the  lingual. 
It  passes  along  the  inferior  surface  of  the  tongue,  just  beneath 
its  mucous  membrane.  At  the  tip  of  the  tongue  it  anastomoses  with 
its  fellow  of  the  opposite  side.  It  is  accompanied  by  the  gustatory 
nerve. 

The  Facial  Artery  is  the  third  branch  of  the  external  carotid.  It 
ascends  to  the  submaxillary  gland,  behind  which  it  passes  on  the  body 
of  the  lower  jaw  ;  thence  it  goes  in  front  of  the  masseter  muscle  to  the 
angles  of  the  mouth,  and  finally  terminates  at  the  side  of  the  nose  by 
anastomosing  with  the  ophthalmic  arteries. 

In  its  course  it  gives  off  the  submental,  inferior  labial,  superior  and 
inferior  coronary  arteries,  which  mainly  supply  the  elevators,  depres- 
sors and  circular  muscles  of  the  mouth.  The  branches  of  the  facial 
artery  are  divided  into  two  sets  : — 

CERVICAL   BRAA'CHES.  FACIAL   BRANCHES. 

Inferior  or  Ascending  Palatine.  Muscular. 

Tonsillitic.  Inferior  Labial. 

Submaxillary.  Inferior  Coronary. 

Submental  Superior  Coronary. 

Lateralis  Nasi. 

Angular. 


BLOOD    VESSELS    OF   THE    TNIOUTH.  85 

The  Inferior  Palatine  passes  up  between  the  stylo-glossus  and  stylo- 
pharyngeus  muscles,  which  it  supplies,  to  give  branches  to  the  tonsil. 
Eustachian  tube,  soft  palate  and  palatine  glands,  anastomosing  with 
the  tonsillitic  artery,  and  with  a  branch  of  the  internal  maxillary. 

The  Tonsillitic  Artery  is  distributed  to  the  tonsil  and  root  of  the 
tongue. 

The  Submaxillary  supplies  the  submaxillary  gland,  together  with 
the  neighboriug  lymphatic  glands,  muscles  and  integuments. 

The  Submental  is  the  largest  of  the  cervical  bi*anches  of  the  facial 
artery  ;  it  is  given  off  from  it  just  as  it  emerges  from  the  submaxillary 
gland,  and,  passing  along  the  lower  border  of  the  inferior  maxilla,  is 
distributed  to  the  muscles  attached  to  the  jaw,  and  terminates  in  a 
superficial  and  deep  branch  ;  the  former  of  which  is  distributed  to  the 
depressor  labii  inferioris  and  integument,  anastomosing  with  the  inferior 
labial ;  the  latter  is  also  distributed  to  the  lip,  and  anastomoses  with 
the  inferior  labial  and  mental  arteries. 

The  Facial  branches  are  distributed  to  the  muscles  of  the  face.  The 
muscular  to  the  pterygoid,  masseter  and  buccinator  muscles.  The 
superior  coronary  to  the  upper  lip,  giving  branches  to  the  septum  and 
ala  nasi.  The  inferior  coronary  passes  to  the  lower  lip,  and  anasto- 
moses with  its  fellow  of  the  opposite  side.  The  lateralis  nasi  sup- 
plies the  wing  and  back  of  the  nose.  The  angular  is  the  terminal 
branch  of  the  facial.  It  supplies  the  cheek,  lachrymal  sac  and  orbicu- 
laris palpebrarum  muscle,  and  terminates  by  anastomosing  with  the 
ophthalmic  by  its  nasal  branch. 

The  Ascending  Pharyngeal,  the  smallest  of  the  external  carotid 
branches,  is  given  off  from  the  posterior  part  of  the  external  carotid, 
passes  up  beneath  its  other  branches  and  the  stylo-phax'yngeus  muscle 
to  the  base  of  the  skull ;  it  has  three  sets  of  branches — the  external, 
meningeal  and  pharyngeal.  To  the  latter  only  do  I  wish  to  direct 
attention. 

The  Pharyngeal  branches  are  three  or  four  in  number,  two  of  which 
are  distributed  to  the  middle  and  inferior  constrictors  and  to  the  stylo- 
pharyngeus,  and  their  mucous  membrane.  The  largest  branch  sup- 
plies the  tonsil,  Eustachian  tube  and  soft  palate,  substituting  the 
palatine  branch  of  the  facial  Avhen  it  is  absent  or  of  small  size. 

The  Temporal  Artery  gives  off  a  transverse  facial  branch  just  before 
it  emerges  from  the  parotid  gland,  which  is  distributed  to  that  gland, 
the  masseter  muscle  and  the  integument,  terminating  by  anastomosis 
with  the  facial  and  infra-orbital  arteries. 

The  Internal  Maxillary  Artery  commences  in  the  substance  of  the 
parotid  gland ;  then  goes  horizontally  behind  the  neck  of  the  condyle 
of  the  lower  jaw  to  the  pterygoid  muscles,  between  which  it  passes,  and 


86  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

then  proceeds  forward  to  the  tuberosity  of  the  superior  maxillary  bone ; 
from  thence  it  takes  a  vertical  direction  upward  between  the  temporal 
and  external  pterygoid  muscles  to  the  zygomatic  fossa,  where  it  again 
becomes  horizontal,  and  finally  ends  in  the  spheno-maxillary  fossa  by 
dividing  into  several  branches. 

The  branches  of  this  artery  which  we  shall  describe  are  the — 

Inferior  Dental.  Alveolar. 

Infra-orbital.  Descending  Palatine. 

The  Inferior  Dental  Artery  enters  the  inferior  dental  foramen  of  the 
lower  jaw,  passes  along  the  dental  canal  beneath  the  roots  of  the  teeth  ; 
sending  up,  in  its  course,  a  twig  through  the  aperture  of  each  to  the 
pulp  of  the  teeth  and  finally,  escapes  at  the  mental  foramen  on  the 
chin  ;  a  branch  of  it,  however,  continues  forward  to  supply  the  incisors- 
After  emerging  from  the  mental  foramen,  it  supplies  the  muscles  and 
integument  of  the  chin  and  anastomoses  with  the  inferior  labial,  sub- 
mental, and  inferior  coronary  arteries.  Before  entering  the  dental 
foramen  a  large  branch,  the  mylo-hyoid,  which  lies  in  a  groove  of  the 
same  name  on  the  inner  surface  of  the  maxillary  bone  and  is  lost  on 
the  under  surface  of  the  mylo-hyoid  muscle,  is  given  off. 

The  Alveolar  is  given  off  from  the  internal  maxillary  by  a  trunk 
common  to  it  and  the  infra-orbital,  just  before  it  enters  the  spheno- 
maxillary fossa.  At  the  tuberosity  of  the  superior  maxillary  bone  it 
divides  into  numerous  branches,  some  of  which  passing  into  the  alveo- 
lar foramina  supply  the  bicuspid  and  molar  teeth  ;  others  pierce  the 
bone  to  supply  the  antrum,  while  some  are  distributed  to  the  gums. 

The  Infra-orbital  Artery  enters  the  infi-a-orbital  canal,  traverses  its 
whole  extent,  and  comes  out  at  the  foramen  of  the  same  name,  upon 
the  face;  just  before  it  emerges  it  sends  through  the  anterior  dental 
canal  a  twig  for  the  incisors  and  cuspids,  having  previously  given 
branches  to  the  inferior  rectus  and  inferior  oblique  muscles,  and  to  the 
lachrymal  gland,  also  other  branches  to  the  lining  membrane  of  the 
antrum.  After  escaping  from  the  orbit,  it  supplies  the  lachrymal  sac 
and  neighboring  tissues  and  anastomoses  with  the  facial,  nasal  branch 
of  the  ophthalmic,  and  with  the  transverse  facial  and  buccal  branch. 

The  Descending  Palatine  passes  along  the  posterior  palatine  canal, 
accompanied  by  palatine  branches  of  Meckel's  ganglion  ;  emerging 
thence  it  runs  along  a  groove  on  the  inner  border  of  the  alveoli,  and  is 
distributed  to  the  mucous  membrane  of  the  hard  palate,  to  the  gums 
and  the  palatine  glands.  In  the  posterior  palatine  canal  it  gives  off 
branches,  which  pass  along  the  accessory  palatine  canal  to  be  dis- 
tributed to  the  soft  palate.  In  front  it  terminates  in  a  small  branch 
which  enters  the  anterior  palatine  canal,  through  which  it  passes  to 


THE  XERVES  OF  THE  MOUTH.  87 

reach  the  septum  naris,  where  it  unites  with  a  branch  of  the  spheno- 
palatine. 

The  Veins  correspond  so  nearly,  both  in  name  and  course,  with  the 
arteries,  that  a  description  of  them  would  only  be  a  repetition  of  what 
has  been  said  ;  suffice  it,  therefore,  to  observe,  that  there  are  two  com- 
panion veins  with  every  considerable  artery,  and  that  the  venous 
branches  are  mostly  collected  at  the  angle  of  the  jaw  into  a  common 
trunk  called  the  external  jugular  vein,  which  passes  down  the  neck  in 
the  course  of  the  fibres  of  the  platysma  muscle,  and  terminates  in  the 
subclavian  vein  at  the  posterior  edge  of  the  steruo-mastoid  muscle. 

The  office  of  the  veins  is  to  I'eturn  the  blood  to  the  heart. 


CHAPTER  VII. 

THE  XERVES  OF  THE  MOUTH. 

THE  nerves  supplying  the  mouth  belong  to  the  fifth  pair,  and  the 
portio  dura  of  the  seventh  or  facial  nerve. 

The  Fifth  (Trigemini)  is  the  largest  of  the  cranial  nerves,  and  gives 
sensibility  to  all  the  organs  concerned  in  the  primary  stages  of  diges- 
tion. 

This  nerve  will  also  be  found  to  be  a  compound  nerve,  having  motor 
filaments  as  well  as  sensitive,  and  thereby  giving  motion  as  well  as 
sensation.     It  is  also  a  nerve  of  special  sense. 

It  is  first  seen  at  the  side  of  the  pons  Varolii  near  its  junction  with 
the  crura-cerebelli,  but  its  origin  is  much  deeper  and  further  back.  It 
ax'ises  by  two  unequal  roots,  one  of  which  may  be  traced  through  the 
pons  Varolii  into  the  lateral  tract  behind  the  olivary  body ;  the  smaller, 
or  motor  root,  is  lost  in  the  medulla  oblongata.  From  its  origins  this 
nerve  has  been  called  a  cranial-spinal  nerve. 

These  two  fasciculi,  the  one  anterior  and  the  other  posterior,  consti- 
tute the  fifth  nerve,  which  consists  of  eighty  or  one  hundred  filaments 
that  pass  forward  and  outward,  in  a  canal  formed  of  dura  mater,  to  a 
depression  on  the  anterior  surface  of  the  petrous  bone. 

At  this  point  it  spreads  into  a  ganglion,  called  the  Casserian  gang- 
lion, on  the  under  surface  of  which  is  seen  the  anterior  root ;  but  it  has 
no  intimate  connection  with  the  ganglion,  and  can  be  traced  on,  as  will 
be  presently  shown,  to  the  inferior  maxillary  nerve. 

The  Casserian  ganglion  receives  filaments  from  the  carotid  plexus 
of  the  sympathetic,  and  gives  ofi"  several  minute  branches  to  the  dui-a 


PRINCIPLES   AjSTD    PEACTICE    OF    DENTISTRY. 


mater  and  tentorium  cerebelli.  Three  large  branches  are  given  off 
from  its  anterior  border,  the  ophthalmic  and  superior  and  inferior 
maxillary.  The  ophthalmic  and  superior  maxillary  are  exclusively 
nerves  of  sensation,  their  fibres  being  derived  entirely  from  the  poste- 
rior or  sensory  root,  whilst  the  inferior  maxillary  receives  fibres  from 
both  roots,  and  is  consequently  more  variously  endowed. 

The  Ophthalmic  Nerve  is  a  short  trunk,  that  enters  the  orbit  through 
the  foramen  lacerum  superius.     It    suiDjolies  the  eyeball,  the  raucous 

Fig.  20. 


SEflSCnV  ROOT 
MOTOR    ROOT^/I    "§C 


AiimcuLo  reMPORAL  n 


membrane  of  the  eye  and  nose,  and  the  lachrymal  gland,  also  the 
muscles  and  integument  of  the  eyebrow  and  forehead.  It  is  a  sensi- 
tive nerve ;  is  the  first  given  off  from  the  Casserian  ganglion,  and  is 
the  smallest  of  the  three  branches.  It  receives  a  few  filaments  from 
the  cavernous  plexus  of  the  sympathetic,  and  divides  into  three  prin- 
cipal branches — 

1.  The  Frontal. 

2.  The  Lachrymal,  and 

3.  The  Nasal. 


THE   SUPERIOE    MAXILLAKY   NERVE.  89 

The  Frontal,  which  is  the  largest  branch  of  the  ophthalmic,  passes 
along  the  roof  of  the  orbit  to  the  supra-orbital  foramen,  through  which 
it  passes,  and  is  then  called  the  supra-orbital  nerve,  and  is  spent  on  the 
muscles  and  integuments  of  the  forehead.  It  gives  off  several  branches 
in  its  course. 

The  Lachrymal,  the  smallest  branch  of  the  ophthalmic,  generally 
arises  by  two  branches,  one  from  the  fourth  nerve  and  the  other  from  the 
ophthalmic.  It  enters  the  orbit  through  the  sphenoidal  fissure,  receives 
a  communicating  branch  from  the  superior  maxillary,  and  is  finally 
distributed  to  the  lachrymal  gland,  taking  the  outward  direction,  and 
sending  branches  in  its  course  to  the  upper  eyelid,  conjunctiva,  and 
other  parts,  receiving  on  the  eyelid  branches  from  the  facial. 

The  Nasal  takes  its  direction  along  the  inner  side  of  the  orbit  to  the 
anterior  ethmoidal  foramen,  through  which  it  passes  into  the  cranium, 
on  the  uppei'.  surface  of  the  cribi'iform  plate  of  the  ethmoidal  bone ; 
descends  by  the  side  of  the  crista-galli  through  a  slit-like  opening  into 
the  nose,  and  there  terminates  by  filaments  which  are  spent  upon  the 
septum,  mucous  membrane,  anterior  nares,  etc.  It  sends  off  several 
branches  in  its  course ;  one  in  particular  to  the  lenticular  ganglion  at 
the  bottom  of  the  eye,  others  to  the  caruncula  lachrymalis,  lachrymal 
sac,  conjunctiva,  etc. ;  but  as  these  do  not  belong  to  the  mouth  and 
dental  a2:>paratus,  we  will  pass  to  the  second  great  division  of  the  fifth. 

THE   SUPERIOR   MAXILLARY   NERVE. 

This  nerve  proceeds  from  the  middle  of  the  Casserian  ganglion, 
passes  through  the  foramen  rotundum  of  the  sphenoid  bone  into  the 
pterygo-maxillary  fossa ;  here  it  enters  the  canal  of  the  floor  of  the 
orbit — the  infra-orbital  canal — traverses  its  whole  extent,  and  emerges 
on  the  face  at  the  infra-orbital  foramen,  where  it  terminates  in  numerous 
filaments  in  the  muscles  and  integuments  of  the  upper  lip,  cheek,  lower 
eyelid  and  side  of  the  nose. 

The  superior  maxillary  nerve  supplies  the  upper  jaw,  and  gives  off 
many  important  branches,  which  are  as  follows: — 

In  the  pterygo-maxillary  fossa  two  branches  descend  to  a  small  red- 
dish body  called  the  ganglion  of  Meckel,  or  the  spheno-palatine  gan- 
glion, situated  on  the  outer  side  of  the  nasal  or  vertical  plate  of  the 
palate  bone. 

From  this  ganglion  proceed  three  sets  of  branches : — • 

1.  Inferior,  Descending  or  Palatine  Nerves. 

2.  Nasal  or  Spheno-palatine. 

3.  Posterior,  Pterygoid  or  Vidian. 

The  Palatine  Nerves  descend  through  the  posterior  palatine  canal, 
come  out  at  the  posterior  palatine  foramen,  along  with  an  artery  of  the 


90  PRIXCIPLES    AXD    PRACTICE   OF    DENTISTRY. 

same  name,  and  supply  with  filaments  the  soft  palate,  uvula,  tonsils, 
the  roof  of  the  mouth  and  the  inner  alveoli  and  gums. 

The  Nasal  Nerves  enter  the  nose  through  the  spheno-palatine  fora- 
men, and  divide  into  several  filaments,  which  enter  the  mucous  mem- 
brane covering  the  upper  and  lower  turbinated  bones  and  vomer ;  one 
long  branch  can  be  traced  along  the  septum  nasi,  as  far  as  the  foramen 
incisivum,  where  it  meets  the  anterior  palatine  branches  in  a  ganglion 
called  the  uaso-palatine. 

The  Vidian,  or  Pterygoid,  passes  backward  from  the  ganglion  of 
Meckel  through  the  pterygoid  canal  at  the  root  of  the  pterygoid  pro- 
cess ;  then  enters  the  cranium  through  the  foramen  lacerum  anterius, 
and  divides  into  two  branches,  one  of  which  enters  the  carotid  canal 
and  unites  with  the  sympathetic  branches  of  the  superior  cervical  gan- 
glion, thus  connecting  this  ganglion  with  the  ganglion  of  Meckel. 

The  other,  the  proper  vidian  nerve,  enters  the  vidian  foramen  or 
hiatus  Fallopii  in  the  petrous  bone,  joins  the  portio  dura  nerve,  accom- 
panies this  as  far  as  the  back  part  of  the  tympanum ;  then  leaves  it, 
enters  the  cavity  of  the  tympanum,  and  receives  there  the  name  of 
Chorda  Tyvipani.  It  leaves  this  cavity  by  the  glenoid  fissure,  then 
joins  the  gustatory  nerve,  continues  with  it  to  the  submaxillary  gland, 
where  it  leaves  it,  and  is  lost  in  the  submaxillary  ganglion,  situated  at 
the  posterior  part  of  the  submaxillary  gland. 

The  exceedingly  intricate  course  of  the  vidian  nerve  is  interesting 
from  the  number  of  communications  which  it  establishes  between  dif- 
ferent and  distant  parts  ;  for  it  unites  the  ganglion  of  Meckel  with  the 
superior  cervical  ganglion  of  the  sympathetic,  and  both  with  the  sub- 
maxillary ganglion ;  it  also  connects  the  superior  and  inferior  maxil- 
lary nerves  to  one  another  and  to  the  portio  dura. 

The  Sujyerior  Maxillary  Nerve  gives  ofi"  next  in  the  spheno-maxil- 
lary  fossa — 

1.  The  Orbital. 

2.  The  Posterior  Dental. 

3.  The  Anterior  Dental. 

The  Orbital  enters  the  orbit  through  the  spheno-maxillary  fissure, 
and  then  sends  oflf  a  malar  and  tehiporal  branch,  which  pass  out 
through  the  malar  bone;  the  first  supplying  the  cheek,  the  latter 
accompanying  the  temporal  artery  to  the  integuments  of  the  side  of  the 
head,  receiving  filaments  from  the  facial  and  auriculo-temporal  branch 
of  the  inferior  maxillary. 

The  Posterior  Dental  Nerves,  two  in  number,  descend  on  the  tuber- 
osity of  the  superior  maxillary  bone,  and  enter  the  posterior  dental 
canals  to  supply  the  bicuspid  and  molar  teeth  ;  one  branch  penetrates 
the  antrum  and  courses  along  the  outer  wall,  anastomosing  with  the 


INFERIOR   MAXILLARY   NERVE.  91 

anterior  dental  nerves,  while  another  runs  along  the  alveolar  border 
supplying  the  gums. 

The  Anterior  Dental  is  given  off  from  the  superior  maxillary,  just 
before  it  escapes  from  the  infra-orbital  foramen.  It  anastomoses  with 
the  posterior  dental,  and  sends  filaments  to  the  incisor,  canine  and 
first  bicuspid  teeth ;  others  are  sent  to  the  mucous  membrane  of  the 
inferior  meatus. 

This  nerve  now  emerges,  as  before  mentioned,  at  the  infra-orbital 
foramen,  between  the  levator  labii  superioris  alseque  nasi  and  levator 
auguli  muscles,  dividing  here  into  many  branches ;  some  of  which 
ascend  to  the  nose  and  eyelids ;  others  pass  downward  and  outward  to 
the  lip  and  cheek,  anastomosing  with  the  nasal  branch  of  the  ophthal- 
mic, and  the  facial  branches  of  the  portio  dura. 

INFERIOR   MAXILLARY   NERVE. 

This  nerve  forms  the  third  great  division  of  the  fifth.  It  is  the 
largest  branch,  and  passes  from  the  ganglion  of  Casser,  through  the 
foramen  ovale  of  the  sphenoid  bone,  to  the  zygomatic  fossa. 

This  nerve,  as  stated,  is  attached  to  the  anterior  or  motor  root,  and 
they  come  together  on  the  outside  of  the  foramen  ovale  ;  then  in  the 
zygomatic  fossa,  the  inferior  maxillary  nerve  divides  into  two  branches  : 

1.  Anterior. 

2.  Posterior. 

The  Anterior  is  the  motor  branch,  and  gives  ofi"  the  following  fila- 
ments to  the  several  muscles  : — 

1.  Masseteric,  crossing  the  sigmoid  notch  to  the  masseter  muscle. 

2.  Temporal,  anterior  and  posterior  deep,  to  the  temporal  muscle 

and.  fascia. 

3.  Buccal,  to  the  buccinator,  external  pterygoid,  and  temporal 

muscles. 

4.  Pterygoid,  to  the  pterygoid  muscles. 

The  Internal  division  of  the  inferior  maxillary  nerve  consists  of  three 
branches,  all  of  which  are  sensitive ;  they  are — 

1.  The  Anterior  Auricular. 

2.  The  Gustatory. 

3.  The  Inferior  Dental. 

The  Anterior  Auricular  passes  behind  the  neck  of  the  lower  jaw  and 
in  front  of  the  meatus  of  the  ear,  and  ascends  through  the  parotid 
gland,  over  the  zygoma,  along  with  the  temporal  artery,  and  divides 
into  anterior  and  posterior  branches. 

In  its  course  it  unites  with  the  facial  nerve,  and  supplies  the  parotid 
gland,  the  articulation  of  the  lower  jaw,  the  meatus,  and  cartilages  of 
the  ear  and  side  of  the  head.     • 


92  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

The  Gustatory  Nerve,  the  nerve  of  the  special  sense  of  taste,  imme- 
diately after  its  origin,  sends  a  branch  to  the  inferior  dental ;  it  then 
descends  between  the  pterygoid  muscles,  where  the  chorda  tympani 
joins  it;  it  now  passes  along  the  ramus  of  the  lower  jaw,  covered  by 
the  internal  pterygoid  muscle,  then  above  the  submaxillary  glands, 
and  forward  above  the  mylo-hyoid  and  between  it  and  the  hyo-glossus 
muscles,  accompanied  by  the  duct  of  Wharton ;  and  finally  ascends 
above  the  sublingual  gland  to  the  lateral,  inferior,  and  anterior  parts 
of  the  tongue.  , 

In  its  course,  Mr.  Harrison  enumerates  the  following  branches  as 
given  off  by  this  nerve  : — 

"  First,  one  or  two  small  filaments  to  the  internal  pterygoid  muscle. 
Second,  several  to  the  tonsils,  to  the  muscles  of  the  palate,  to  the  upper 
part  of  the  pharynx,  and  to  the  mucous  membrane  of  the  gums. 
Third,  the  chorda  tympani,  and  some  accompanying  filaments  to  form 
a  plexus,  which  supplies  the  submaxillary  gland.  Fourth,  a  few 
branches  which  descend  along  the  hyo-glossus  muscle  to  communicate 
with  the  ninth  or  lingual  nerve.  Fifth,  a  fasciculus  of  nerves  to  the 
sublingual  gland  and  to  the  surrounding  mucous  membrane.  Lastly, 
at  the  tongue  it  divides  into  several  branches ;  some  pass  deep  into  the 
tissue  of  this  organ;  others,  firm  and  soft,  rise  toward  its  surface,  and 
are  lost  in  the  mucous  membrane  and  in  a  small  conical  papilla  near 
its  tip." 

The  Inferior  Dental  Nerve  passes  between  the  pterygoid  muscles, 
then  along  the  ramus  of  the  lower  jaw  under  the  pterygoideus  internus 
to  the  inferior  dental  foramen,  which  it  enters  along  with  an  artery  and 
vein  ;  it  now  traverses  the  inferior  dental  canal,  sending  twigs  into  all 
the  roots  of  the  molars  and  bicuspids.  Opposite  the  mental  foramen 
it  divides  into  two  branches;  the  smaller  is  continued  forward  in  the 
substance  of  the  jaw  to  supply  the  roots  of  the  cuspids  and  incisors  ; 
while  the  larger  comes  out  at  the  mental  foramen,  is  distributed  to  the 
muscles  and  integuments  of  the  lower  lip,  and  finally  communicates 
with  the  facial  nerve. 

The  inferior  dental,  just  as  it  enters  the  posterior  dental  foramen, 
gives  off  the  mylo-hyoid  nerve  ;  this  passes  forward  in  a  groove  of  the 
lower  jaw,  and  supplies  the  mylo-hyoid  and  digastrie  muscles,  and  oc- 
casionally the  submaxillary  gland. 

THE   FACIAL    NERVE. 

The  Portia  dura  of  the  seventh  or  facial  nerve  is  the  last  nerve  to 
be  noticed  as  particularly  belonging  to  the  mouth. 

The  Facial  Nerve  arises  from  the  medulla  oblongata  between  the 
olivary  and  restiform  bodies,  close  behind  the  lower  margin  of  the 


THE    FACIAL    NERVE. 


93 


pons  Varolii ;  it  then  passes  forward  and  outward  with  the  portio 
mollis  to  the  foramen  auditorium  internum,  which  it  enters  and  passes 
on  to  the  base  of  this  opening ;  here  these  two  nerves  separate,  the 
portio  mollis  going  to  the  labyrinth  of  the  ear ;  while  the  facial  enters 
the  aqueduct  of  Fallopius,  in  which  it  is  joined  by  the  vidian.     Within 

Fig.  21. 


rERyiNAT/OiVS 
f        I  ht/PKfl  TFIOCHL  eA  tt 

\  IVf/?/l  TROCHLHAR 

F 
fJASAL 


the  aqueductus  Fallopii  it  gives  off  two  branches — the  tympanic  and 
chorda  tympani.  The  former  supplies  the  stapedius  muscle.  The  latter 
passes  along  a  distinct  canal  and  enters  the  cavity  of  the  tympanum 
near  the  attachment  of  the  membrana  tympani,  where  it  is  covered  by 
mucous  membrane.     It  escapes  from  this  cavity  by  the  inner  side  of 


94  PRINCIPLES   AXD    PRACTICE    OF   DENTISTRY. 

the  Glasserian  fissure ;  after  receiving  a  communicating  branch  from 
the  gustatory  nerve  it  passes  to  the  submaxillary  gland,  then  joining 
the  submaxillary  ganglion  it  is  lost  in  the  lingual  muscle.  The 
facial  then  goes  in  a  curved  direction  outward  and  backward  behind 
the  tympanum,  where  it  parts  with  the  vidian,  and  proceeds  on  to  the 
stylo-mastoid  foramen,  from  which  it  emerges.  At  this  point  it  sends 
off  three  small  branches — 

1.  The  Posterior  Auricular, 

2.  The  Stylo-hyoid,  and. 

3.  The  Digastric. 

The  Posterior  Auricular  ascends  behind  the  ear,  crosses  the  mastoid 
process,  where  it  receives  branches  from  the  pneumogastric,  and  the 
auricularis  magnus ;  it  then  divides  into  two  branches,  one  of  which 
passes  to  the  retrahens  aurem,  the  other  to  the  occij)ito-frontalis 
muscle. 

The  Stylo-hyoid  is  distributed  to  the  stylo-hyoid  muscle.  It  com- 
municates with  filaments  of  the  sympathetic  sent  to  the  carotid 
artery. 

The  Digastric  is  distributed  to  the  posterior  belly  of  the  digastric 
muscle,  receiving  a  communicating  branch  from  the  glosso-pharyn- 
geal. 

The  facial  nerve,  while  deeply  imbedded  in  the  substance  of  the 
parotid  gland,  divides  into  two  sets  of  branches,  of  which  one  is 
superior  and  the  other  inferior ;  these  two,  by  frequent  unions,  form 
the  pes  anserinus  or  parotidean  plexus,  and  send  branches  to  the  w^hole 
of  the  side  of  the  face. 

The  ujjper  division,  called  the  temporo-facial,  ascends  in  front  of 
the  ear  upon  the  zygoma,  accompanies  the  temporal  artery,  and  its 
branches,  supplying  the  side  of  the  head,  ear,  and  forehead,  and  anas- 
tomosing with  the  occipital  and  supra-orbital  nerves;  a  set  of  branches 
pass  transverely  to  the  cheek,  furnishing  the  lower  eyelid,  lips,  and 
side  of  the  nose,  and  uniting  with  the  infra-orbital  nerve. 

The  inferior  or  cervico-facial  division  descends,  supplying  the  lower 
jaw  and  upper  part  of  the  neck,  giving  off  the  following   branches : — 

1.  Buccal. 

2.  Inferior  Maxillary,  and 

3.  Cervical. 

The  Buccal,  or  superior  branches,  supply  the  muscles  of  the  cheek, 
nose,  and  upper  lip. 

The  Inferior  Maxillary  nerves  are  distributed  in  the  muscles  of  the 
chin  and  lower  lip,  and  by  means  of  anastomotic  branches  communi- 
cate with  the  inferior  dental  nerve. 

The  Cervical  branches  form  a  close  connection  with  the  superior  cer- 


SALIVARY   GLANDS   AND   SALIVA.  95 

vical  nerves,  and  supply  the  platysma  myoid  and  the  levator  labii 
superioris  muscles. 

The  fiicial  is  the  motor  nerve  of  the  face,  and  by  its  means  the  pas- 
sions or  emotions  find  their  expression  in  the  peculiar  action  of  the 
muscles  to  which  it  is  distributed. 

In  consequence  of  the  numerous  communications  which  this  nerve 
has  with  other  nerves,  the  name  of  Sympatheticus  Minor  has  been  given 
to  it  by  some  anatomists. 

Mr.  Gray  furnishes  the  following  concise  statement  of  these  com- 
munications : — 

In  the  internal  auditory  meatus,  With  the  auditory  nerve. 

f      With  Meckel's  ganglion  by  the  large 
petrosal  nerve. 

With  the  optic  ganglion  by  the  smaller 
In  the  aquseductus  Fallopii,  -j   petrosal  nerve. 

With  the  sympathetic  on  the  middle 
meningeal  by  the  external  petrosal 
nerve. 

With  the  pneumogastric. 
At   its   exit  from   the    stylo-mastoid     J  \\      \\     glosso^pharyngeal. 


foramen, 


-|  "      "     carotid  plexus 

I  "      "     auricularis  magnus. 

L  "      "     auriculo-temporal. 

On  the  face With  the  three  divisions  of  the  fifth. 


CHAPTER  VIII. 

SALIVARY    GLANDS   AND   SALIVA. 

THE  Salivary  Glands  are  six  in  number,  three  on  each  side  of  the 
face,  named  the  Parotid,  Suhynaxillary  and  Sublingual. 

These  glands  are  the  prime  organs  in  furnishing  the  salivary  fluids 
to  the  mouth  during  the  process  of  mastication. 

The  Parotid  Gland  (Fig.  22),  so  called  from  its  situation  near  the 
ear,  is  the  largest  of  the  salivary  glands.  Its  form  is  very  irregular ; 
it  tills  the  space  lying  between  the  ramus  of  the  inferior  maxilla  and 
mastoid  process  of  the  temporal  bone,  as  far  back  as,  and  even  behind, 
the  styloid  process  of  the  same  bone.  Its  extent  of  surface  is  from 
the  zygoma  above  to  the  angle  of  the  lower  jaw  below,  and  from  the 
mastoid  process  and  meatus  behind  to  the  masseter  muscle  in  front, 
overlapping  its  posterior  portion. 

This  gland  is  one  of  the  conglomerate  order,  and  consists  of  numerous 
small  lobes  connected  together  by  cellular  tissue,  each  of  which  may 


96 


PRINCIPLES   AXD    PRACTICE    OF    DENTISTRY. 


be  considered  a  small  glaud  in  miniature,  as  each  is  supplied  with  an 
artery,  vein  and  excretory  duct. 

The  gland  thus  formed  presents  on  its  external  surface  a  pale,  flat 
and  somewhat  convex  appearance. 

It  is  covered  by  a  dense,  strong  fascia,  extending  from  the  neck,  and 
attached  to  the  meatus  externus  of  the  ear,  which  sends  countless  pro- 
cesses into  every  part  of  the  gland,  se]Darating  its  lobules  and  conducting 
the  vessels  through  its  substance. 

The  use  of  this  gland  is  to  secrete  or  separate  from  the  blood  the 

Fig.  22. 


greater  part  of  the  saliva  furnished  to  the  mouth.  As  the  parotid  is, 
however,  on  the  outside,  and  at  some  little  distance  from  the  mouth,  it 
is  furnished  with  a  duct  to  convey  its  fluid  into  this  'cavity ;  this  duct 
is  called  the  duct  of  Steno,  or  the  parotid  duct.  It  is  formed  of  the 
excretory  ducts  of  all  the  granules  composing  this  gland,  which,  suc- 
cessively uniting  together,  at  last  form  one  common  duct. 

The  duct  of  Steno  commences  at  the  anterior  part  of  the  gland  and 
passes  over  the  masseter  muscle,  on  a  line  drawn  from  the  lobe  of  the 
ear  to  the  middle  part  of  the  upper  lip ;  then  passes  through  a  quan- 


COMPOSITION   OF   HUMAN   PAROTID   SALIVA.  97 

tity  of  soft  adipose  matter,  and  finally  enters  the  mouth  by  passino- 
through  the  buccinator  muscle  and  mucous  membrane,  opposite  the 
second  molar  of  the  upper  jaw. 

The  arteries  supplying  this  gland  are  from  the  external  carotid  or 
some  of  its  branches. 

The  nerves  are  derived  from  the  carotid  plexus  of  the  sympathetic, 
and  from  the  facial,  temporal,  and  great  auricular. 

The  parotid  secretion  is  a  clear,  watery,  alkaline  liquid,  which  is 
poured  out  abundantly  during  mastication,  but  in  very  small  quantity 
when  the  mouth  is  at  rest.  Its  secretion  may  also  be  excited  by  men- 
tal emotion,  as  when  observing  a  savory  article  of  food,  or  by  artificial 
stimuli,  as  of  glass  beads  or  other  irritants  in  the  mouth. 

The  following  analysis  is  taken  from  Dalton's  Physiology : — 

COMPOSITION    OP   HUMAN    PAROTID   SALIVA. 

Water,            ........  983.308 

Organic  Matter  precipitable  by  alcohol,             ....  7.352 

Substance  destructible  by  heat,  but  not  precipitated  by  alcoholar  acids,  4  810 

Sulpho-cyanide  of  Sodium,  ......  0.330 

Phosphate  of  Lime,         ••.....  0.240 

Chloride  of  Potassium,          ......  0.900 

Chloride  of  Sodium  and  Carbonate  of  Soda,      ....  3.060 


Total,         .......  1000.000 

It  will  be  seen  that  the  quantity  of  organic  matter  is  comparatively 
large. 

Observation  has  shown  that  this  secretion  is  unilateral,  the  saliva 
flowing  only  from  that  side  on  which  mastication  is  then  being  con- 
ducted, and  that  the  quantity  is  directly  related  to  the  physical  char- 
acter of  the  food,  and  not  to  its  chemical  constitution,  being  more  or 
less  abundant,  according  to  the  dryness  of  the  food. 

The  Sal) maxillary  is  the  next  in  size  of  the  salivary  glands.  It 
is  situated  under  and  along  the  inferior  edge  of  the  body  of  the 
lower  jaw,  and  is  separated  from  the  parotid  simply  by  a  process  of 
fascia. 

It  is  of  oval  form,  pale  color,  and  like  the  parotid,  consists  in  its 
structure  of  small  lobules,  held  together  by  cellular  tissue;  each  having 
a  small  excretory  duct,  which,  successively  uniting  with  one  another, 
finally  form  one  common  duct.  This,  the  duct  of  Wharton,  passes 
above  the  mylo-hyoid  muscle,  and  running  forward  and  hiward,  enters 
the  mouth  below  the  tip  of  the  tongue  at  a  papilla  seen  on  either  side 
of  the  frseuum  linguae. 

The  use  of  this  gland  is  the  same  as  the  parotid,  to  secrete  a  fluid 
constituent  of  the  saliva,  and  its  duct  is  the  route  by  which  it  is  con- 
7 


98  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

ducted  into  the  mouth.  Its  arteries  are  derived  from  the  facial  and 
lingual.  The  veins  correspond.  Its  nerves  are  received  from  the  sub- 
maxillary ganglion,  the  inferior  dental  and  sympathetic  nerves. 

The  Subungual  Glands  are  the  last  in  order  of  the  salivary  glands, 
and  the  smallest  in  size. 

They  are  situated  beneath  the  anterior  and  lateral  parts  of  the  tongue, 
are  covered  by  the  mucous  membrane,  and  rest  upon  the  mylo-hyoid 
muscle. 

They,  like  the  two  glands  just  described,  consist  of  a  lobular  struc- 
ture with  excretory  ducts  ;  which,  however,  do  not  unite  iiito  one  com- 
mon duct,  but  enter  the  cavity  of  the  mouth  by  many  ducts,  whose 
openings  are  through  the  mucous  membrane  between  the  tongue  and 
the  inferior  cuspid  and  bicuspid  teeth. 

Their  office  is  the  same  as  the  parotid  and  submaxillary.  Their 
arteries  are  derived  from  the  sublingual  and  submental.  Their  nerves 
from  the  gustatory ;  salivary  glands  are  found  in  all  vertebrate 
animals  except  fishes. 

The  Mucous  Glands.  Besides  the  glands  furnishing  the  saliva,  there 
is  another  series  of  much  smaller  size,  called  the  mucous  glands.  They 
are  simply  the  little  crypts,  follicles,  or  depressions  everywhere  found 
in  the  mucous  membrane  of  the  mouth,  and  named,  according  to  their 
situation,  the  glandulse  labiales,  glandulee  buccales,  etc.  The  lijDS, 
cheeks,  and  palate  are  also  furnished  with  glands,  about  the  size  of  a 
small  pea,  which  present  the  true  salivary  structure. 

The  use  of  these  glands  is  to  furnish  the  mucus  of  the  mouth,  which 
they  pour  into  this  cavity  by  single  orifices,  opening  everywhere  on  its 
surface. 

The  Saliva  consists  of  the  commingled  secretion  of  all  these  glands. 
It  is  a  glairy,  slightly  opalescent,  alkaline  fluid,  consisting  of  organic 
and  mineral  substances  held  in  solution  with  water.  Its  composi- 
tion, according  to  Bidder  and  Schmidt,  is  as  follows: — 

COMPOSITION    OF   SALIVA. 

Water, 995.16 

Organic  Matter, L34 

Sulpho-cyanide  of  Potassium, 0.06 

Phosphate  of  Soda,  Lime,  and  Magnesia,          ....  .98 

Chlorides  of  Sodium  and  Potassium, .84 

Mixture  of  Epithelium, 1.62 

1000.00 

Two  kinds  of  organic  matter  exist  in  the  saliva ;  the  first,  which  is 
found  in  the  submaxillary  and  sublingual  secretions,  is  QdW^di  ptyaline ; 
to  it  the  saliva  owes  its  viscidity.    Alcohol  coagulates  it,  but  heat  does 


THE   TONGUE.  99 

not,  differing,  in  this  respect,  from  the  organic  matter  derived  from 
the  parotid  gland,  which  is  coagulated  by  heat  and  is  not  viscid. 

Sulpho-cyanogen,  the  only  mineral  ingredient  that  is  peculiar  to 
saliva,  is  detected  by  a  solution  of  the  chloride  of  iron,  with  which  it 
strikes  a  red  color  characteristic  of  it. 

When  saliva  has  stood  for  some  time  it  deposits  a  whitish  flocculent 
sediment,  which  is  found  under  the  microscope  to  consist  of  epithelium 
scales,  and  other  small  nucleated  cells,  granular  matter,  and  oil  globules. 
Although  saliva  possesses  the  power  to  change  the  starchy  matter  of 
the  food  into  sugar,  yet  in  view  of  the  facts  that  this  change  is  inter- 
rupted by  the  gastric  juice  with  which  it  is  so  soon  to  come  in  contact, 
and  that  the  quantity  secreted  is  directly  related  to  the  physical  char- 
acteristics of  the  food,  and  not  to  its  chemical  constitution,  not  being 
more  abundant  during  the  mastication  of  starchy  food,  except  it  be 
dry,  than  of  any  other  aliment,  and,  furthermore,  since  the  conversion 
of  starch  into  sugar  is  otherwise  provided  for,  it  may  be  considered  as 
an  established  fact  that  its  only  purpose  is  to  aid  mechanically  in  mas- 
tication and  deglutition  by  moistening  and  lubricating  the  food.  The 
quantity  of  saliva  secreted  daily  has  been  variously  estimated  by 
different  observers.  Mitscherlich  thought  it  about  fourteen  ounces 
daily,  and  Todd  and  Bowman  consider  his  estimate  reliable.  Bidder 
and  Schmidt  estimated  it  at  about  three  and  a  half  pounds  avoirdupois, 
and  Mr.  Dalton  at  "  rather  less  than  three  pounds  avoirdupois,"  which 
is  probably  very  nearly  correct. 

THE   TONGUE. 

The  Tongue  is  a  very  complicated  organ;  it  consists  of  a  great 
variety  of  parts,  and  performs  a  great  variety  of  functions ;  it  is  one 
of  the  organs  of  deglutition ;  a  glandular  organ,  to  secrete ;  a  sentient 
organ,  to  feel  and  taste ;  and  likewise  an  intellectual  organ,  to  assist 
in  producing  speech. 

The  tongue  is  divided  into  apex,  body  and  root;  the  apex  is  the  ante- 
rior free  and  sharp  portion ;  the  root,  which  is  thin,  is  attached  to  the 
OS  hyoides  and  is  j)osterior;  while  the  body,  which  occupies  the  centre, 
is  thick  and  broad ;  it  is  confined  in  its  situation  by  the  origins  of  its 
component  muscles,  and  by  reflections  of  the  mucous  membrane. 

The  mucous  membrane  of  the  tongue  covers  its  free  surface  every- 
where; it  is  thinnest  on  its  under  surface,  where  it  may  be  traced 
along  the  ducts  of  the  submaxillary  and  sublingual  glands.  Passing 
over  the  dorsum,  it  assumes  a  papillary  character,  and  becomes  much 
thickened. 

The  papillae  of  the  tongue  are  the  papillse  circumvallata?,  papillie 
fungiformes,  and  papillae  filiformes. 


100  PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 

The  papillae  circumvallatse  (maximse)  are  situated  on  each  side  of 
the  back  part  of  the  tongue,  meeting  at  the  foramen  caecum  so  as  to 
form  a  triangular  figure.     They  number  from  eight  to  fifteen. 

Each  papilla  is  arranged  in  the  form  of  an  inverted  cone,  Avith  its  apex 
received  into  a  depression  of  mucous  membrane,  and  its  base  exposed  on 
the  free  surface,  and  upon  it  may  be  seen  numerous  smaller  papillaj. 

The  papillae  fungiformes  are  scattered  irregularly  over  the  surface 
of  the  tongue,  but  are  most  numerous  at  its  sides  and  apex.  They 
also  are  studded  on  their  free  surface  with  smaller  papillae. 

The  papillae  filiformes  are  found  on  the  anterior  two-thirds  of  the 
tongue,  and  are  very  minute.  They  are  somewhat  conical  or  filiform 
in  shape,  are  covered  with  an  unusually  dense  epithelium  which  gives 
them  a  whitish  appearance,  and  are  filled  with  secondary  papillae. 
Small  hairs  are  often  found  in  them. 

Structure  of  the  Papillce. — They  consist  of  capillary  loops,  through 
which  nerves  are  abundantly  distributed,  covered  by  a  homogeneous 
tissue,  upon  which  is  superposed  a  thick  layer  of  squamous  epithelium. 

The  nerves  are  large  and  numerous  in  the  papillae  circuravallatae ; 
in  the  papillae  fungiformes  and  papillae  filiformes  they  are  smaller. 

In  the  mucous  membrane  are  also  found  follicles  or  glands.  The 
former  are  very  numerous,  especially  so  between  the  circumvallate 
papillae  and  the  epiglottis,  but  are  found  scattered  over  the  entire  sur- 
face of  the  tongue.  The  latter,  called  mucous  or  lingual  glands,  are 
most  abundant  on  the  posterior  third  of  the  tongue,  but  are  found  also 
on  its  tip,  sides,  and  in  the  neighborhood  of  the  circumvallate  papillae. 
The  ducts  open  on  the  free  surface  of  the  mucous  membrane. 

THE    MUCOUS   MEMBRANE   LINING   THE   MOUTH. 

The  whole  interior  cavity  of  the  mouth,  palate,  j)harynx,  and  lips, 
is  covered  by  mucous  membrane,  forming  folds  or  duplicatures  at  dif- 
ferent points,  called  frsena  or  bridles.  Beginning  at  the  margin  of  the 
lower  lip,  this  membrane  can  be  traced  lining  its  posterior  surface,  and 
from  thence  reflected  on  the  anterior  face  of  the  lower  jaw,  where  it 
forms  a  fold  opposite  the  symphysis  of  the  chin — the  fraenum  of  the 
lower  lip ;  it  is  now  traced  to  the  alveolar  ridge,  covering  it  in  front, 
and  passing  over  its  posterior  surface,  where  it  enters  the  mouth.  Here 
it  is  reflected  from  the  posterior  symphysis  of  the  lower  jaw  to  the 
under  surface  of  the  tongue,  where  it  forms  a  fold  or  bridle,  called  the 
frcenum  linguce.  It  now  spreads  over  the  tongue,  covering  its  dorsum 
and  sides  to  the  root,  from  whence  it  is  reflected  to  the  epiglottis,  form- 
ing another  fold ;  from  this  point  it  can  be  followed,  entering  the 
glottis  and  lining  the  larynx,  trachea,  etc. 

In  the  same  way,  commencing  at  the  up^Der  lip,  it  is  reflected  to  the 


THE    MUCOUS    MEMBRANE    IJNING   THE    MOUTH. 


101 


upper  jaw,  and  at  the  upper  central  incisors,  forming  a  fold,  the  frcenum 
of  the  upper  lip;  from  this  it  passes  over  the  alveolar  ridge  to  the 
roof  of  the  mouth,  which  it  completely  covers,  and  extends  as  far  back 
as  the  posterior  edge  of  the  palate  bones  ;  from  this  it  is  reflected  down- 
ward over  the  soft  palate,  or,  more  strictly  speaking,  the  soft  palate  is 
formed  by  the  duplicature  of  this  membrane  at  this  point,  between  the 
folds  of  which  are  placed  the  muscles  of  the  palate  already  described. 

From  the  palate  it  is  traced  upward  and  continuous  with  the  mem- 
brane lining  the  nares,  and  downward  with  the  same,  lining  the 
pharynx,  oesophagus,  stomach  and  intestinal  canal. 

The  mucous  membrane,  after  entering  the  nostrils  and  lining  the 
roof,  floor,  septum  nasi  and  turbinated  bones,  enters  the  maxillary 
sinus,  between  the  middle  and  lower  spongy  bones,  and  lines  the  whole 
of  this  great  and  important  cavity  of  the  superior  maxilla. 

Many  mucous  glands  or  follicles,  already  enumerated,  are  scattered 
over  the  whole  of  this  membrane,  and  furnish  the  mouth  with  its 
mucus. 

The  mucous  membrane  of  the  mouth,  which  is  directly  concerned 

in  the  development  of  the  teeth,  and  afterwards  is  in  close  relation 

with  these  organs,  is  composed  of  different  layers,  as  follows : — 

_,.,..         (  Corneous. 
ii,pitheliura.  ^  ,r  i    •   i  • 
^  I  Malpighian. 

Basement  Membrane. 

f  Papillarv. 
Corium  or  Proper  Mucous  Membrane,  -j  T?p4.;„^^oVy 

Submucous  Areolar  Tissue. 

The  epithelium,  which  corresponds  to  the  epidermis  of  the  skin,  is 
composed  of  two  layers,  an  external  and  an  inter- 
nal. The  external  layer,  of  horny  consistence,  and 
known  as  the  corneous  layer — stratum  cornewn — 
is  formed  of  old  epithelial  cells,  which,  owing  to 
changes  from  prismatic  or  columnar  cells  during 
their  migration  from  the  internal  to  the  external 
surface  of  the  membrane,  have  become  thin,  devi-  C 
talized  scales,  devoid  of  function.  These  old  epi- 
thelial cells  are  being  continually  cast  off  as  effete 
matter,  others  taking  their  places,  which,  in  turn, 
undergo  a  similar  process  of  devitalization  and 
exfoliation. 

The  internal  or  Malpighian  layer  is  formed  of  ^.Epitheiium:6m.tase- 
living  epithelial  scales  or  cells,  which  are  of  various  ment  membrane;  c.  co- 
forms  and  sizes,  and  are  placed  vertically  upon   ri"n,;D.  submucous  areo- 


Fig.  23. 


E 


bm 


DIFFEREN'T   LAYERS   OF   MU- 
COVS   MEMBRANE. 


the  "  basement  membrane,"  which  separates  the 


102 


PRIIS'CIPLES   AND   PRACTICE   OF   DENTISTRY. 


epithelium  from  the  corium  (proper  mucous  membrane).  The  cells  of 
this  internal  layer  are  variously  designated  as  the  prismatic,  columnar, 
cylindrical  or  Malpighian  layer,  and  have  large 
nuclei,  but  are  destitute  of  a  cell  wall.  This  layer 
constitutes  the  peripheral  portion  of  the  enamel 
organ,  which  during  the  development  of  a  tooth 
is  known  as  the  "enamel  membrane." 

The  basement  membrane,  known  as  the  mem- 
brance  prceforynativa  of  Raschow,  is  situated  below 
the  internal  or  Malpighian  layer,  and  is  a  homo- 
geneous structure,  which  in  some  parts  partakes 
of  the  character  of  a  membrane,  especially  where 
it  is  of  considerable  thickness. 
Although  not  usually  recognized  as  a  layer  of  the  mucous  mem- 
brane, yet  it  is  interesting  from  the  fact  that  the  dentine  bulb  or  germ 

Fig.  25.  Fig.  26. 


Fig.  24. 


CELLS  COMPOSING  THE  STRA- 
TUM CORNEUM  OR  EXTER- 
NAL LAYER  OF  EPITHE- 
LIUM (from  FREY). 


INTERNAL  OR  MALPIGHIAN  LAYEK  OF 
THE  EPITHELIUM. 

a.  Infant  cells,  known  as  prismatic, 
coluninar  or  cylinder  cells;  6.  inter- 
mediate matter;  d.  fibrous  tissue  of 
the  corium. 

Fig.  27. 


a.  Flat  layer  of  epithelial  cells  thrown  upward 
into  the  "  burrelet"  of  Legros  and  Magitot;  6.  en- 
largement and  proliferation  of  cells  in  cuboidal 
layer,  forcing  flat  layer  upward  and  columnar  layer 
downward ;  c.  columnar  layer  of  cells  directly  over 
position  which  will  be  occupied  by  future  jaw. 


Mb 


htn 


and  the  ertamel  organ  are  found  on  the  oppo- 
site sides  of  it,  the  former  below  and  the 
latter  above  it. 

The  Corium  or  mucosa,  which  is  the  proper 
mucous  membrane,  is  situated  beneath  the 

r  M  basement  membrane,  and  is  analogous  to  the 

^4  derma  of  the  skin.     It  consists  of  a  fibro- 

vascular  layer  of  variable  thickness,  merging 
into  the  submucous  areolar  tissue,  and  con- 
tains, besides  the  white  and  yellow  fibrous 
tissue  and  the  vessels,  muscular  fibre  cells 
(forming  what  is  known  in  some  localities 
as  the  muscularis  mucosce),  nerves  and  lym- 
phatics. 
Mucous  glands  project  from  its  surface,  and   with  the    j^rocesses 

known  as  villi  and  papillae,  common  to  mucous  membrane  covering 

the  tongue,  are  analogous  to  the  papillae  of  the  skin. 


a.  Stiatum  corueum ;  6. 
stratum  Malpighii:  b  m. 
basement  membrane ;  c. 
corium. 


THE   ALVEOLO-DENTAL   PERrOSTEUM.    '  103 

THE   GUM, 

The  gum  is  composed  of  dense,  elastic,  fibrous  tissue,  adhering  to 
the  periosteum  of  the  alveolar  tissue.  It  is  remarkable  for  its  insen- 
sibility and  hardness  in  the  healthy  state,  but  exhibits  great  tenderness 
upon  the  slightest  injury,  when  diseased.  The  gum  differs  in  texture 
from  that  of  the  mucous  membrane  lining  the  inside  of  the  lips,  cover- 
ing the  floor  of  the  mouth  and  the  palate,  of  which  it  is  a  continuation, 
by  being  thicker  and  denser,  and  of  less  sensibility.  Its  hardness  is 
due,  in  a  great  measure,  to  the  numerous  tendinous  fasciculi  in  its 
substance,  and  also  to  its  being  closely  blended  with  the  dense  fibrous 
fasciculi  of  the  periosteum,  which  causes  it  to  closely  adhere  to  the 
bone.  These  fasciculi  of  the  gum,  arising  from  the  periosteum,  expand 
in  fan-like  form  as  they  approach  the  epithelial  surface.  The  sub- 
stance of  the  gum  contains  broad-based  papillse,  either  single  or  com- 
pound, and  the  epithelium  is  formed  of  lamin?e  of  tesselated  cells, 
very  much  flattened  near  the  surface,  but  with  cylindrical  cells 
composing  the  Malpighian  or  deepest  layer.  The  gums  are  very 
vascular,  being  freely  supplied  with  vessels,  but  with  few  nerves. 
A  free  margin  of  gum,  about  half  a  line  in  width,  surrounds  the 
base  of  each  tooth,  and  they  present  a  festooned  appearance,  caused 
by  elongations  in  the  interdental  space.  The  portion  of  the  gum 
which  adheres  to  the  neck  of  the  tooth  is  of  a  very  fibrous  structure. 
At  the  necks  of  the  teeth  the  gum  is  continuous  with  the  periosteum 
of  the  inner  surface  of  the  alveoli,  being  reflected  back  upon  itself, 
and  uniting  with  the  true  peridental  membrane.  The  gum  of  the 
upper  jaw  is  supplied  with  vessels  from  the  superior  coronary  artery, 
and  that  of  the  lower  jaw  from  the  submental  and  sublingual 
arteries.  They  derive  their  nerves  from  the  superior  dental  branches 
of  the  fifth  pair. 

In  the  infant  state  of  the  gum,  the  central  line  of  each  dental  arch 
presents  a  white,  firm,  cartilaginous  ridge,  which  gradually  becomes 
thinner  as  the  teeth  advance;  and  in  old  age,  after  the  teeth  drop  out, 
the  gum  again  resumes  somewhat  its  former  infantile  condition,  show- 
ing "  second  childhood," 

The  gum,  being  endowed  with  a  high  degree  of  vascularity,  indicates 
very  correctly,  as  the  author  has  stated  in  another  part  of  this  work, 
the  state  of  the  constitutional  health. 

THE   ALVEOLO-DENTAL   PERIOSTEUM. 

The  dental  periosteum  lines  the  alveolar  cavities  or  sockets  of  the 
teeth,  covers  the  roots  of  each,  is  attached  to  the  gums  at  the  necks, 
and  to  the  blood  vessels  and  nerves  where  they  enter  the  roots  of  the 
teeth  at  their  apices ;  and,  further,  Mr.  Thomas  Bell  believes  it  passes 


104  PRINCIPLES   AND    PRACTICE   OF    DENTISTRY. 

into  the  cavities  of  the  teeth,  forming  their  lining  membrane,  and  is 
continuous  with  or  the  same  as  that  of  the  pulp. 

Mr.  Charles  Tomes,  in  describing  this  membrane,  says  :  "  It  is  thicker 
near  to  the  neck  of  the  tooth,  where  it  passes  by  imperceptible  grada- 
tions into  the  gum  and  periosteum  of  the  alveolar  process,  and  near  to 
the  apex  of  the  root.  The  general  direction  of  the  fibres  is  transverse 
— that  is  to  say,  they  run  across  from  the  alveolus  to  the  cemeutum, 
without  break  of  continuity,  as  do  also  many  capillary  vessels ;  a  mere 
inspection  of  the  connective  tissue  bundles,  as  seen  in  a  transverse  sec- 
tion of  a  decalcified  tooth  in  its  socket,  will  suffice  to  demonstrate  that 
there  is  but  a  single  'membrane,'  and  that  no  such  thing  as  a  mem- 
brane proper  to  the  root  and  another  proper  to  the  alveolus  can  be 
distinguished ;  and  the  study  of  its  development  alike  proves  that  the 
soft  tissue  investing  the  root  and  that  lining  the  socket  are  one  and 
the  same  thing ;  that  there  is  but  one  '  membrane,'  namely,  the 
alveolo-dental  periosteum.  At  that  part  which  is  nearest  to  the  bone 
the  fibres  are  grouped  together  into  conspicuous  bundles ;  it  is,  in  fact, 
much  like  any  ordinary  fibrous  membrane.  On  its  inner  aspect,  where 
it  becomes  continuous  with  the  cementum,  it  consists  of  a  fine  network 
of  interlacing  bands,  many  of  which  lose  themselves  in  the  surface  of 
the  cementum.  But  although  there  is  a  marked  difference  in  histo- 
logical character  between  the  extreme  parts  of  the  membrane,  yet  the 
markedly  fibrous  elements  of  the  outer  blend  and  pass  insensibly  into 
the  bands  of  the  fine  network  of  the  inner  part,  and  there  is  no  break 
of  continuity  whatever.  At  the  surface  of  the  cementum  it  is  more 
richly  cellular,  and  here  occur  abundantly  large,  soft,  nucleated  plasm 
masses,  which  are  the  osteoblasts  concerned  in  making  cementum,  and 
which,  by  their  offshoots,  communicate  with  plasm  masses  imprisoned 
within  the  cementum."  According  to  Wedl,  the  vascular  supply  of 
the  dental  periosteum  is  derived  from  the  gums,  the  vessels  of  the 
bone,  and  the  vessels  destined  for  the  pulp  of  the  tooth,  the  last  being 
the  most  important.  The  nerves  supplying  the  dental  periosteum  are 
derived  from  the  dental  pulp  and  from  the  nerves  of  the  bone ;  hence 
it  is  apparent  that  the  relationship  between  the  pulp  and  periosteum 
of  the  teeth  is  very  intimate. 

ANATOMICAL   RELATIONS   OF   THE   MOUTH. 

The  mouth  has  many  interesting  anatomical  relations  with  the  rest 
of  the  body,  a  few  of  which  it  may  be  well  to  mention. 

By  means  of  its  lining  mucous  membrane  it  is  connected,  through 
continuity  of  structure,  with  the  pharynx,  oesophagus,  stomach  and  the 
whole  of  the  intestinal  canal,  etc. 

Disease  still  further  establishes  this  structural  relation.     Inflamma- 


PHYSIOLOGICAL   RELATIONS   OF   THE   MOUTH.  105 

tion,  ulceration,  or  any  other  pathological  change  in  the  stomach  or 
intestines,  is  felt  and  reported  on  the  tongue,  gums  and  other  parts  of 
the  mouth,  showing  the  sympathy  and  the  cIqsb  relationship  of  these 
several  parts. 

The  mouth  is  also  connected  by  the  same  mucous  membrane  with 
the  organs  of  respiration,  by  being  continued  down  into  the  larynx, 
trachea  and  bronchi. 

Widespread  sympathies  are  established  between  the  mouth  and 
other  parts  by  means  of  the  numerous  nerves  which  animate  the  parts 
constituting  its  boundaries  and  lying  in  its  cavity,  as  the  sympathetic, 
the  seventh,  the  glosso-pharyngeal,  the  par  vagum,  the  hypoglossal, 
and  upper  cervical. 

Simple  irritation  from  teething  has  thrown  children  into  convul- 
sions, and  in  adults  toothache  often  creates  extreme  irritability  of  the 
whole  nervous  system.  But  it  is  not  necessary  to  dwell  here  on  the 
sympathies  of  the  mouth  in  disease  with  other  parts  of  the  body,  as  the 
author  will  have  occasion  to  do  this  in  other  parts  of  this  work. 

It  will  be  well,  however,  to  mention  in  this  place,  that  there  is  a 
general  anatomical  relation  of  the  mouth  with  the  rest  of  the  body,  by 
means  of  the  blood  vessels  and  areolar  tissue. 

PHYSIOLOGICAL    RELATIONS    OF    THE   MOUTH. 

It  has  been  shown  that  the  mouth  consists  of  a  great  variety  of  parts, 
and,  also,  that  it  has  an  equally  great  diversity  of  functions. 

The  functions  of  the  mouth  have  been  stated  to  be  those  of  prehen- 
sion, mastication,  insalivation,  and  deglutition. 

These  functions,  it  has  been  seen,  are  all  closely  related  to  one 
another,  and  mutually  dependent ;  and  how  beautiful  is  the  harmony 
of  action  as  well  as  its  regular  and  orderly  succession  I  We  see,  in 
the  first  place,  the  prehensile  instruments  laying  hold  of  and  intro- 
ducing the  food  into  the  mouth  ;  then  the  organs  of  mastication,  the 
teeth  and  upper  and  lower  jaw  bones,  put  into  operation  by  the  tem- 
poral, masseter  and  pterygoid  muscles,  grind  it  down  into  minute  por- 
tions ;  these,  at  the  same  time,  are  formed  into  a  bolus  by  being  mixed 
with  the  salivary  fluids  furnished  by  the  parotid,  submaxillary  and 
sublingual  glands  ;  then  the  mass  is  taken  by  the  organs  of  deglu- 
tition, namely,  the  tongue,  palate  and  pharynx,  and  passed  into  the 
cesophagus,  to  be  thence  conducted  into  the  stomach,  thus  demon- 
strating the  harmony  existing  among  the  several  functions  belonging 
to  the  mouth. 

But  the  functional  relation  of  the  mouth  is  no  less  extensive  than 
its  structural  relation ;  the  one  is  commensurate  with  the  other ;  and 
as  the  structure  of  the  mouth  has  been  shown  to  be  continuous  with 


106 


PRIXCIPLES    AND    PRACTICE    OF    DENTISTRY. 


that  of  other  parts  of  the  body,  so  we  find  that  the  functions  of  the 
mouth  exert  an  influence  upon,  and  are  themselves  influenced  by,  many 
great  and  leading  functions  of  the  body.  The  connection  between 
mastication  and  insalivation,  for  example,  with  stomachal  digestion,  or 
chymification,  is  especially  obvious. 

Again,  the  mouth  is  intimately  related  with  the  intellectual  func- 
tious,  as,  for  instance,  that  of  speech.  Who  does  not  know  that  when 
any  of  the  teeth  are  wanting,  the  palate  cleft,  or  there  is  a  hare-lip, 
how  much  the  speech  is  impaired?  And  so  with  all  the  other  func- 
tions of  the  body ;  the  relations  between  them  and  the  mouth,  and  the 
mutual  dependence  of  each  on  the  other,  is  equally  demonstrable. 


CHAPTER  IX. 


THE   TEETH. 

THE  teeth  in  the  human  mouth  are  the  prime 
organs  of  mastication,  are  the  hardest  portion 
of  the  body,  and  are  implanted  in  the  alveolar 
cavities  of  both  the  up2:)er  and  lower  jaw. 

A  tooth  is  composed  of  four  distinct  structures  : 
1.  The  j5w/p,  occupying  the  chamber  in  the  crown 
and  the  canal  extending  through  the  root ;  2.  The 
dentine,  which  constitutes  the  principal  part  of 
the  organ ;  3.  The  enamel,  which  forms  the  covering 
and  protection  of  the  crown;  4.  The  cementum,  or 
crusta petrosa,  which  covers  the  root.  (See  Fig.  28.) 
Two  sets  of  teeth  are  developed  in  the  mouth, 
one  of  first  dentition  and  one  of  second  dentition. 

The  teeth  of  first  dentition,  termed  the  milk, 
temporary,  or  deciduous  teeth,  are  designed  merely 
to  supply  the  wants  of  childhood,  and  are  re- 
placed with  a  larger,  stronger,  and  more  numerous 
set.  The  teeth  of  second  dentition  are  termed  the 
permanent  or  adult  teeth,  and  are  intended  to 
continue  through  life. 

The  anatomical    divisions  of  a  tooth  are  :     1. 

a.  The  coronal  surface  di-  xhe  crowu  or  exposed   part,  situated  above   the 

rntine°c.the"uip  cavity;  g^^ ;  2.  The  root.  Occupying  the  alveolar  cavity 

J.  the  cementum,  or  crnsta  or  socket ;  3.  The  neck,  which  is  the  constricted 

petrosa;  e.  the  enamel.  x-         i.    ^  ^i  i  j. 

portion  between  the  crown  and  root. 


TEMPORARY   AND    PERMANENT   TEETH. 


107 


THE   TEMPORARY   TEETH. 

The  temporary  teeth  are  divided  into  three  classes:  first,  the 
incisors;  second,  the  cuspids,  or  canine  teeth;  third,  the  molars,  which 
are  succeeded  by  the  bicuspids  or  premolars. 

The  temporary  teeth  are  twenty  in  number,  ten  in  each  jaw,  namely : 
four  incisors,  two  cuspids,  and  four  molars. 


Fig.  29. 


Fig.  30. 


FRONT   OR    LABIAI,  VIEW   OF   THE   TEMPORARY 
TEETH    OF   THE    LEFT   SIDE. 


PALATINF.   OR   LINGUAL    VIEW   OF   THOSE   ON 
THJE   EIGHT   SIDE. 


The  pulp-cavity  in  a  temporary  tooth  is  larger  in  proportion  to  the 
size  of  the  organ  than  in  a  permanent  tooth. 


Fig.  31. 


Fig.  82. 


LATERAL   OP.    SIDE  VIEW   OF   TEMPORARY   TEETH.        SECTION  OF  DITTO,  EXPOSING  THEIR  PULP  CAVITIES. 


THE   PERMANENT   TEETH. 


There  are  thirty-two  teeth  in  the  permanent  set,  sixteen  to  each 
jaw — being  an  increase  of  twelve  over  the  temporary,  designated  as 
follows :.  incisors,  four ;  cuspids,  two ;  bicuspids  or  premolars,  four ; 
molars,  six — in  each  jaw.     The  surfaces  of  the  teeth  covered  by  the 


108 


PRINCIPLES   AXD   PEACTICE   OF   DENTISTRY. 


lips  are  called  "labial;"  by  the  cheeks,  "buccal;"  toward  the  roof 
of  the  mouth  on  the  upper  jaw,  "palatal;"  toward  the  tongue  on  the 
lower  jaw,  "  lingual."  The  name  "  proximate"  is  given  to  the  surfaces 
next  to  each  other;  the  surfaces  looking  toward  the  centre  are  called 
"  mesial ;"  and  those  looking  from  the  centre,  "  distal." 

DESCRIPTION   OF   TEETH   BELONGING   TO    EACH   CLA.SS. 

Each  tooth,  as  has  already  been  remarked,  has  a  body  or  crown,  a 
neck,  and  a  root  or  fang.  In  describing  these  several  parts,  I  shall 
begin  with 

The  Incisors  (four  to  each  jaw,  and  so  called  from  the  Latin  word 
incidere,  to  cut;  on  account  of  their  sharp,  cutting  edges  (Fig.  33), 
a  a,  a  a).    They  occupy  the  anterior  central  part  of  each  maxillary  arch. 

Fig.  33. 


aa,  aa.  Front  view  of  the  incisors ;  bb,hb.  palatine  or  lingual  view ;  c  c,  c  c.  side  or  lateral  view. 


The  body  of  each  is  wedge  shape — the  anterior  or  labial  surface  is 
convex  and  smooth ;  the  posterior  or  palatal  is  concave,  and  presents 
a  tubercle  near  the  neck ;  the  palatal  or  labial  surfaces  come  together, 
and  form  a  cutting  edge.  In  a  front  view,  the  edge  is  generally  the 
widest  part ;  it  diminishes  toward  the  neck,  and  continues  narrowing 
to  the  extremity  of  the  root. 

The  crown  of  an  incisor  has  four  surfaces :  two  proximate,  one 
labial,  and  one  palatal  or  lingual — the  term  palatal  being  applied  to 
an  upper,  and  lingual  to  a  lower,  incisor.  It  also  has  four  anglee  ; 
namely,  a  right  and  a  left  labio-j)roximate,  and  a  right  and  left  palato- 
proximate,  or  lingua-proximate. 

The  two  large  incisors  which  are  situated  one  on  each  side  of  the 


THE   crSPIDATI,  OR   CUSPIDS. 


109 


median  line,  are  termed  the  central  incisors ;  the  other  two,  the  lateral 
incisors,  or  laterals,  because  they  occupy  a  position  on  either  side  of 
the  centrals.  The  cru\Yns  of  the  upper  central  incisors  are  about  four 
lines  in  breadth,  and  the  laterals  three.  In  the  lower  jaw,  the  crowns 
of  the  central  incisors  are  only  about  two  lines  and  a  half  in  width, 
while  the  laterals  are  usually  a  little  wider.  But  the  width  of  the 
crowns  of  all  the  incisors  varies  in  different  individuals. 

The  length  of  a  superior  central  incisor  is  usually  about  one  inch, 
and  that  of  a  lateral  is  half  of  a  line  less.  In  the  lower  jaw  the  central 
incisors  are  only  about  ten  lines  in  length  ;  the  laterals  are  about  one 
line  and  a  half  longer. 

The  length  of  the  crown  of  an  incisor  is  exceedingly  variable.  That 
of  an  upper  central  varies  from  four  and  a  half  to  six  lines;  and  there 
is  the  same  want  of  uniformity  in  this  respect  with  the  crowns  of  all 
the  incisors. 

The  roots  are  all  single,  of  a  conical  form,  flattened  laterally,  and 
slio:htlv  furrowed  lonoitudinallv.  The  enamel  is  thicker  before  than 
behind,  and  thinnest  at  the  sides. 

The  function  of  this  class  of  teeth,  as  their  name  imports,  is  to  cut 
the  food,  and  for  the  performance  of  this  office  they  are  admirably 
fitted  by  their  shape.  As  age  advances,  their 
edges  often  become  blunted ;  but  the  rapidity  with 
which  they  are  worn  away  depends  altogether 
upon  the  manner  in  which  those  of  the  upper  and 
lower  jaw  come  together. 


THE   CUSPIDATI,   OR   CUSPIDS. 

The  Cuspidati,  Canini,  or  Cuspids,  so  called 
from  the  Latin  word  cmpis,  "a  point,"  because 
they  terminate  in  a  point,  are  commonly  known 
by  the  name  of  canines  (Fig.  34),  and  are  situated 
next  to  the  incisors,  two  to  each  jaw,  one  on  either 
side.  They  somewhat  resemble  the  upper  central 
incisors  with  their  angles  rounded.  Their  ci'owns 
are  conical,  very  convex  externally,  and  their 
palatal  surface  more  uneven,  and  have  a  larger 
tubercle  than  the  incisors.  Their  roots  are  also 
larger,  and  of  all  the  teeth  the  longest ;  like  the 
incisors,  they  are  also  single,  but  have  a  groove 
extending  from  the  neck  to  the  extremity,  show- 
ing a  step  toward  the  formation  of  two  roots.  A 
cuspid,  like  an  incisor,  has  four  surfaces  and  four 
angles,  designated  by  the  names  already  given. 


Fig. 


a  a.  Front  riew  of  the  cus- 
pids; 6  6.  palatine  and  lin- 
gual view ;  c  c.  side  view. 


110 


PEIN'CIPI.ES    AND    PRACTICE    OF    DENTISTRY, 


The  breadth  of  the  crown  of  an  upper  cuspid  is  about  four  lines, 
that  of  a  lower  is  about  three  and  a  half;  but,  as  in  the  case  of  the 
incisors,  the  width  of  the  crowns  of  these  teeth  is  variable.  The  length 
of  a  cuspid  is  greater  than  that  of  any  other  tooth  in  the  dental 
series — it  being  about  thirteen  lines.  The  breadth  of  the  neck  of  one 
of  these  teeth  is  about  one-third  greater  in  front  than  behind,  and 
from  before  backward  it  measures  about  four  lines. 

The  upper  cuspids,  with  no  good  reason,  are  sometimes  called  eye 
teeth ;  the  lower  are  termed  stomach  teeth. 

These  teeth  are  for  tearing  the  food,  and  in  some  of  the  carnivorous 
animals,  where  they  are  very  large,  they  not  only  rend  but  also  hold 
their  prey. 

The  incisors  and  cuspids  together  are  termed  the  oral  teeth. 


THE   BICUSPIDS. 

The  Bicuspids,  so  called  from  the  Latin  words  hU,  "  twice,"  and 
cuspis,  "a  point,"  (Fig.  35),  four  to  each  jaw,  and  two  on  either  side, 
are  next  in  order  to  the  cuspids.  They  have  two  distinct  prominences 
or  cusps  on  their  grinding  surfaces.  They  are  also  named  pre-molars 
or  the  small  molars,  but  are  more  commonly  designated  as  the  first 
and  second  bicuspids.  They  are  thicker  from  their  buccal  to  their 
palatine  surface  than  either  of  the  incisors,  and  are  flatter  on  their 
sides.  The  grinding  surface  of  each  is  surmounted  by  two  conical 
tubercles,  separated  by  a  groove  running  in  the  direction  of  the  alveo- 
lar arch ;  the  outer  is  larger  and  more  prominent  than  the  inner. 
In  the  lower  jaw  these  tubercles  are  smaller  than  in  the  upper,  and 
the  inner  is  sometimes  wholly  wanting. 

A  bicuspid  has  five  sur- 
faces :  namely,  two  proxinude, 
one  anterior  and  one  pjode- 
rior ;  one  buccal;  one  pjalatal 
or  lingual  surface,  as  the  tooth 
may  be  in  the  upper  or  lower 
jaw,  and  one  grinding  sur- 
face. It  has  also  four  angles ; 
one  anterior  and  one  piosterior 
pjalato-proximate,  and  one  an- 
terior and  one  poderior  bncco- 
pjroximate  angle. 

The  size  of  these  teeth,  like 
that  of  the  incisors  and  cus- 
pids, is  variable.    The  buccal 

aa,  aa.  Buccal  view  of  the  bicuspids ;  bb,bb.  palatine  r  n       i  r 

and  Ungual  view  ;cc,cc.  side  view.  SUrfaCe     Ot     the     CrOWU     ol     a 


THE   MOLARS. 


Ill 


superior  bicuspid  of  ordinary  size  at  its  broadest  part  is  about  three 
lines  in  breadth,  while  the  anterior  and  posterior  approximal  surfaces 
are  about  four  lines.  The  palatal  is  not  quite  as  wide  as  the  buccal 
surface.  All  the  diameters  of  the  crow'n  of  a  lower  bicuspid  are 
usually  a  little  less  than  those  of  an  upper.  The  entire  length  of 
a  bicuspid  is  ordinarily  about  eleven  lines. 

The  superior  bicuspids  have  generally  two  roots,  but  sometimes  a 
single  root,  which  is  often  deeply  grooved,  while  the  inferior  bicuspids 
have  but  one  root.  Of  the  two  roots  of  the  superior  bicuspids,  the 
inner  or  palatal  is  smaller  than  the  outer  or  buccal,  each  root  having 
an  opening  for  the  vessels  and  nerves  to  enter. 

THE   MOLAES. 

The  Molars,  so  called  from  the  Latin  word  molaris,  "  grrindine," 
and  designated  as  first,  second,  and  third  molars  (Fig.  36),  occupy  the 
posterior  part  of  the  alveolar  arch,  and  are  six  in  each  jaw',  three  on 

Fig,  36. 


either  side.  The  first,  owing  to  the 
period  of  their  eruption,  are  called 
the  sixth-year  molars,  and  the  sec- 
ond, for  the  same  reason,  are  called 
the  twelfth-year  molars,  while  the 
third  are  called  the  deutes  sapientise 
or  wisdom  teeth,  from  the  Latin 
•wordsdens,  "  a  tooth,"  a.nd sapientia, 
"  wisdom,"  being  erupted  at  a  period 
when  maturity  is  reached.  The 
molars  are  distinguished  by  their 
greater  size — the  first  and  second 
being  the  largest;  the  grinding 
surfaces  have  the  enamel  thicker, 


a  a  a,  a  a  a.  Outer  view  of  the  molars ;  bbb, 
6  6  6.  inner  view ;  c  c  c,  co  c.  side  view. 


112  PEI^'CIPLES    AXD    PRACTICE    OF    DENTISTRY. 

and  are  surmounted  by  four  or  five  tubercles  or  cusps,  with  as  many- 
corresponding  depressions  arranged  in  such  a  manner  that  the  tuber- 
cles of  the  upper  jaw  are  adapted  to  the  depi-essions  of  the  lower,  and 
vice  versa. 

A  molar,  like  a  bicuspid,  has  also  five  surfaces  and  five  angles,  desig- 
nated by  the  names  already  given. 

The  upper  molars  have  three  roots,  sometimes  four,  and  as  many  as 
five  are  occasionally  seen ;  of  these  roots  two  are  situated  externally? 
almost  parallel  with  each  other,  and  perpendicular;  the  third  root 
forms  an  acute  angle,  and  looks  toward  the  roof  of  the  mouth.  The 
former  are  called  the  buccal  roots,  and  the  latter  the  palatal.  The  roots 
of  the  first  two  superior  molars  correspond  with  the  floor  of  the  max- 
illary sinus,  and  sometimes  protrude  into  this  cavity,  their  divergence 
securing  them  more  firmly  in  their  sockets.  The  lower  molars  have 
but  two  roots — the  one  anterior,  the  other  posterior  ;  they  are  nearly 
vertical,  parallel  with  each  other,  and  much  flattened  laterally. 

The  last  molar,  or  wisdom  tooth,  is  both  shorter  and  smaller  than 
the  others ;  the  roots  of  the  upper  wisdom  tooth  are,  occasionally,  united 
so  as  to  form  but  one;  while  the  last  molar  of  the  lower  jaw  is  gener- 
ally single  and  of  a  conical  form. 

The  roots  of  the  molar  teeth,  both  of  the  upper  and  lower  jaw,  after 
diverging,  sometimes  approach  each  other,  embracing  the  intervening 
bony  j)artition  in  such  a  manner  as  to  constitute  an  obstacle  to  their 
extraction. 

The  bucco-palatal  diameter  of  the  crown  of  an  upper  molar  is  usually 
a  little  less  than  the  antero-posterior.  In  the  lower  jaw,  the  bucco- 
lingual  and  antero-posterior  diameters  are  generally  about  the  same. 

The  crown  of  the  first  molar  is  generally  larger  than  the  second, 
and  the  second  larger  than  the  third  or  wisdom  tooth  ;  and  the  crown 
of  the  last-named  tooth  is  always  smaller  in  the  up^^er  than  in  the 
lower  jaw. 

The  length  of  a  molar  tooth  varies  from  eight  to  twelve  and  a  half 
or  thirteen  lines. 

The  molars  and  bicuspids,  together  constitute  what  are  termed  the 
buccal  teeth. 

The  use  of  the  molars,  as  their  name  signifies,  is  to  triturate  or  grind 
the  food  during  mastication,  and  for  this  purpose  they  are  admirably 
adapted  by  their  mechanical  arrangement. 

AETICULATION    OF   THE   TEETH. 

The  manner  in  which  the  teeth  are  confined  in  their  sockets,  is  by  a 
union  called  gomphosis,  from  the  resemblance  of  this  kind  of  articula- 
tion to  the  wav  in  which  a  nail  is  received  into  a  board.     Those  teeth 


RELATIONS   OF   TEETH   OF   UPPER   AND    LOWER  JAWS.       113 

having  but  oue  root,  and  those  with  two  perpendicular  roots,  depend 
greatly,  for  the  strength  of  their  articulation,  on  their  nice  adaptation 
to  their  sockets. 

Those  having  three  or  four  roots  have  their  firmness  much  increased 
by  their  divergence. 

But  there  are  other  bonds  of  union  ;  by  the  periosteum  lining  the 
alveolar  cavities,  and  investing  the  roots  of  the  teeth  ;  also  by  the 
blood  vessels  entering  the  apices  of  the  roots  ;  and  finally,  by  the  gums, 
which  will  be  noticed  in  another  place. 

DIFFERENCES   BETWEEN    THE    TEMPORARY     AND   PERMANENT   TEETH. 

The  temporary  and  permanent  teeth  differ  in  several  respects,  and 
on  this  point  I  will  give  Mr.  Bell's  observations : — 

"  The  temporary  teeth  are,  generally  speaking,  much  smaller  than 
the  permanent ;  of  a  less  firm  and  solid  texture,  and  their  character- 
istic forms  and  prominences  much  less  strongly  marked.  The  incisors 
and  cuspids  of  the  low^er  jaw  are  of  the  same  general  form  as  in  the 
adult,  though  much  smaller ;  the  edges  are  more  rounded,  and  they  are 
not  much  more  than  half  the  length  of  the  latter.  The  molars 
of  the  child,  on  the  contrary,  are  considerably  larger  than  the  bicuspids 
which  succeed  them,  and  resemble  very  nearly  the  permanent  molars. 

"  The  roots  of  the  tooth  in  the  molars  of  the  child  are  similar  in 
number  to  those  of  the  adult  molars,  but  they  are  flatter  and  thinner 
in  proportion,  more  hollow^ed  on  their  inner  surfaces,  and  diverge 
from  the  neck  at  a  more  abrupt  angle,  forming  a  sort  of  arch." 

RELATIONS  OF  THE  TEETH  OF  THE  UPPER  TO  THOSE  OF  THE 
LOW^ER  JAW,  WHEN  THE  MOUTH  IS  CLOSED. 

The  crowns  of  the  teeth  of  the  upper  jaw  generally  describe  a  rather 
larger  arch  than  those  of  the  lower.  The  upper  incisors  and  cuspids 
usually  shut  over  and  in  front  of  the  lower ;  but  sometimes  they  fall 
plifmb  upon  them,  and  at  other  times,  though  rarely,  they  come  on 
the  inside.  The  external  tubercles  or  cusps  of  the  superior  bicuspids 
and  molars  generally  strike  on  the  outside  of  those  of  the  corresponding 
inferior  teeth.  By  this  beautiful  adaptation  of  the  tubercles  of  the 
teeth  of  one  jaw  to  the  depressions  of  those  of  the  other,  every  part  of 
the  grinding  surface  of  these  organs  is  brought  into  immediate  contact 
in  the  act  of  mastication  ;  which  operation  of  the  teeth,  in  consequence, 
is  rendered  more  perfect  than  it  would  be  if  the  organs  came  together 
in  any  other  manner. 

The  incisors  and  cuspids  of  the  upper  jaw  are  broader  than  the 
corresponding  teeth  in  the  lower ;  in  consequence  of  this  diflference  in 
the  lateral  diameter  of  the  teeth  of  the  two  jaws,  the  central  incisors 


114 


PEINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


of  the  upper  cover  the  centrals  and  about  half  of  the  laterals  in  the 
lower,  while  the  superior  laterals  cover  the  remaining  half  of  the 
inferior  and  the  anterior  half  of  the  adjoining  cuspids.  Continuing 
this  peculiar  relationship,  the  upper  cuspids  close  over  the  remaining 
half  of  the  lower  and  the  anterior  half  of  the  first  inferior  bicuspids, 
while  the  first  superior  bicuspids  cover  the  remaining  half  of  the  first 
inferior  and  the  anterior  half  of  the  second.  In  like  manner,  the 
second  bicuspids  of  the  upper  jaw  close  over  the  posterior  half  of  the 
second   and  the  anterior  third  of  the  first  molars  in  the  lower.     The 

first  superior  molars  cover  the  re- 
maining  two-thirds  of  the  first 
inferior  and  the  anterior  third 
of  the  second,  while  the  two- 
thirds  of  this  last  and  anterior 
third  of  the  lower  dentes  sapi- 
entise  are  covered  by  the  second 
upper  molars.  The  dentes  sapi- 
entipe  of  the  superior  maxilla, 
being  usually  about  one-third 
less  in  their  antero-posterior 
diameter,  cover  the  remaining 
two-thirds  of  the  corresponding 
teeth  in  the  lower  jaw.  (See 
Fig.  37.) 

Thus,  from  this  arrangement  of  the  teeth,  it  will  be  seen,  that  when 
the  mouth  is  closed,  each  tooth  is  opposed  to  two ;  and  hence,  in  biting 
hard  substances  and  in  mastication,  by  extending  this  mutual  aid,  a 
power  of  resistance  is  given  to  these  organs  which  they  would  not 
otherwise  possess.  Moreover,  as  an  English  writer,  Mr.  Tomes,  very 
justly  observes,  if  one,  or  even  two  adjoining  teeth  should  be  lost, 
the  corresponding  teeth  in  the  other  jaw  would,  to  some  extent,  still 
act  against  the  contiguous  organs,  and  thus,  in  some  degree,  coun- 
teract a  process,  first  noticed  by  that  eminent  dentist,  Dr.  L.  Koecker, 
which  nature  sometimes  sets  up  for  the  expulsion  of  such  teeth  as  have 
lost  their  antagonists. 


ORIGIN   AND    FORMATION   OF   THE   TEETH.  115 


CHAPTER  X. 

ORIGIN   AND    FORMATION   OF   THE   TEETH.* 

OF  all  the  operations  of  the  animal  economy,  none  are  more  curious 
or  interesting  than  that  which  is  concerned  in  the  production  of 
the  teeth.  In  obedience  to  certain  developmental  laws,  established  by 
an  all-wise  Creator,  it  is  carried  on  from  about  the  sixth  week  of  intra- 
uterine existence,  with  the  nicest  and  most  wonderful  regularity  until 
completed,  and  excites  in  the  mind  of  the  physiologist  the  highest 
admiration. 

From  small  papillae,  observable  at  a  very  early  period  of  foetal  life, 
the  teeth  are  gradually  developed,  and  as  they  increase  in  size,  the 
papillse  assume  the  shape  of  the  crowns  of  the  several  classes  of  teeth 
they  are  respectively  destined  to  produce.  Having  arrived  at  this 
stage  of  their  formation,  they  now  begin  to  dentinify,  first  upon  the 
cutting  edges  of  the  incisors,  the  apices  of  the  cuspids,  bicuspids  and 
eminences  of  the  molars ;  from  thence  the  process  is  continued  over  the 
whole  surface  of  their  crowns,  until  they  become  invested  with  a  com- 
plete layer  of  dentine ;  and  so  layer  after  layer  is  formed,  one  within 
the  other,  until  the  process  of  solidification  is  completed.  Before  the 
appearance  of  the  dentinal  germ  or  papilla,  however,  the  enamel  of 
the  teeth  begins  to  form,  and  when  the  enamel  organ  or  cord  has 
acquired  the  appearance  of  a  hood  or  cap,  and  contemporaneous  with 
this  change,  the  dentinal  papilla  is  developed,  and  this  formative 
operation  is  gone  through  with  previously  to  the  completion  of  the 
dentinification  of  the  pulp. 

In  the  meantime,  and  in  anticipation  of  the  loss  of  the  temporary 
teeth,  a  second  set  is  forming,  and  as  the  teeth  of  the  one  series  are 
removed,  they  are  promptly  rej^laced  by  those  of  the  other.  Thus, 
by  a  beautiful  and  most  admirable  provision  of  Nature,  the  first  set 
of  teeth,  intended  to  subserve  the  wants  only  of  childhood,  while  the 
jaws  are  too  small  for  the  reception  of  such  as  are  required  for  an 
adult,  are  removed  and  replaced  by  a  larger,  stronger,  and  more 
numerous  set. 

The  older  writers,  regarding  a  knowledge  of  the  earlier  stages  of 
the  development  of  the  teeth  as  not  of  much  importance,  paid  little 
attention  to  the  subject,  and  hence  this  most  curious  and  interesting 

*  The  study  of  the  '•  origin  and  formation  of  the  teeth"  should  begin  with 
the  "development  of  the  bones  of  the  head  and  face,"'  and  the  "  description  of 
the  mucous  membrane,"  to  which  subjects  the  reader  is  referred. 


116  PRINCIPLES   AND    PRACTICE   OF    DENTISTRY. 

department  of  developmental  anatomy  has  remained,  until  recently, 
measurably  uncultivated.  Eustachius,  we  believe,  Avas  the  first  to 
notice  the  position  and  arrangement  of  the  teeth  in  the  jaws  previous 
to  their  eruption.  But  his  researches  were  confined"  to  the  examina- 
tion of  the  jaws  after  birth,  at  which  pei'iod  he  speaks  of  having  dis- 
covered, by  dissection,  the  incisors,  cuspids,  and  three  molars  on  each 
side,  in  each  jaw,  partly  in  a  gelatinous  and  partly  in  a  solidified 
condition.  He  also  discovered  the  incisors  and  cuspids  of  the  per- 
manent set  behind  the  first. 

Eustachius  wrote  in  1563,  and  nineteen  years  later  Urbian  Her- 
mard,  a  French  anatomist  and  surgeon,  although  unacquainted  Avith 
the  work  of  the  former,  gave  a  very  similar  description  of  the  situa- 
tion of  the  crowns  of  the  incisors  and  cuspids  of  both  sets  in  the  jaws 
of  an  infant  at  birth.  He  represents  them  as  partly  bony  and  partly 
mucilaginous.  He  also  discovered  the  bicuspids ;  but  he  was  unable 
to  find  the  molars  at  so  early  a  period  as  at  birth. 

The  researches  of  Albinus  threw  no  additional  light  upon  the 
manner  of  the  formation  of  the  teeth,  and  little  was  known  con- 
cerning the  earlier  stages  of  the  development  of  these  organs  until 
the  time  of  John  Hunter,  who  informs  us  that  in  the  alveoli  of  a 
foetus  of  three  or  four  months  "  four  or  five  pulpy  substances,  not 
very  distinct,  are  seen." 

Although  Mr.  Hunter  gives  a  more  minute  description  of  the  pro- 
gress of  the  formation  and  arrangement  of  the  teeth  in  the  jaws  pre- 
viously to  their  eruption  than  any  previous  writer,  yet,  with  regard  to 
their  origin  and  appearance  during  the  earlier  stages  of  their  develop- 
ment, he  is  unsatisfactory.  Nor  do  the  researches  of  Jourdain,  Blake, 
Fox,  Cuvier,  Serres,  Delabarre,  Bell,  and  other  writers,  throw  much 
additional  light  upon  the  subject.  In  fact,  they  could  not,  as  their 
researches,  except  those  of  Mr.  Bell,  do  not  seem  to  have  been  com- 
menced at  periods  sufliciently  early  in  foetal  subjects ;  and  even  from 
the  time  when  they  were  first  instituted,  the  progress  of  the  organs 
does  not  appear  to  have  been  traced  through  the  subsequent  stages 
of  their  formation  with  the  requisite  degree  of  care  and  accuracy. 
It  is  not,  therefore,  necessary  to  notice  the  descriptions  given  by  these 
authors  of  the  progress  of  the  formation  of  the  teeth. 

The  theories  of  Arnold  and  Goodsir,  and  especially  the  latter,  have 
been  till  recently  universally  accepted,  but  the  later  researches  of 
Waldeyer  and  Dursy  have  shown  them  to  be  erroneous,  and  the  theory 
of  Waldeyer  is  now  generally  adopted.* 

^  According  to  the  theory  of  Goodsir,  at  an  early  period  of  foetal  life  there 
appears  a  continuous  open  groove  running  around  the  whole  circumference  of  the 
jaws.     From  the  bottom  of  this  groove,  which  he  styles  the  primitive  dental 


ORIGIN   AND    FORMATION    OF   THE   TEETH.  117 

Commencing  the  description  of  the  development  of  the  teeth  with 
the  condition  of  the  jaws  of  the  embryo  at  the  period  of  the  formation 
of  the  organs  which  compose  the  "  dental  follicle,"  namely,  the  enamel 
organ,  the  dentinal  germ  or  papilla,  and  the  follicular  wall  or  sac, 
there  is  at  an  early  period  no  trace  of  osseous  tissue  in  the  lower  jaw, 
the  maxillary  arch  having  within  its  component  elements  a  symmetri- 
cal cartilaginous  band,  which  extends  its  entire  length,  as  far  as  the 
frame  of  the  drum  of  the  ear,  and  which  is  known  as  "  Meckel's  carti- 
lage." This  cartilage  acts  a  transitory  part  only,  until  osseous  tissue  is 
developed,  when  it  atrophies  and  disappears.  (See  Development  of 
the  Bones  of  the  Head  and  Face.     Figs.  2,  3  and  4.) 

As  regards  the  upper  ]?i'^,  the  same  period  of  evolution  as  that  of  the 
lower  jaw  marks  the  union  of  the  maxillary  germs  with  the  median  or 
inter-maxillary  germs,  which  occurs  in  the  human  embryo  about  the 
fortieth  or  forty-fifth  day.  On  the  surface  or  rounded  portion  of  the  two 
maxillary  arches  thus  formed,  and  which  later  constitute  the  alveolar 
border  or  process,  a  depression  or  groove,  called  the  "  dental  groove," 
appears,  which,  however,  is  so  completely  filled  or  "heaped  up"  with  a 
bed  of  epithelial  cells  as  to  form  a  protuberance  or  smooth  ridge, 
destitute  of  any  fold  or  depression  whatever. 

This  ridge  (Fig.  38)  is  composed  of  a  thick  bed 
of  epithelial  cells,  which,  however,  on  its  sides 
form  a  coat  of  a  few  rows  of  cells  only,  and  does 
not  include  any  other  well  defined  tissue  unless  l- 
it  be  some  vessels,  nerves,  and  muscle-fibres  in 
process  of  development. 

The  principal  structures  of  the  teeth  are  derived 
from   such   elements   as   compose   the    epithelial 
structure  and  the  tissues  beneath  which  represent     <j.  a  mass  of  epithelium— 
the  corium  and  cellular  tissue  of  the  mucous  mem-  the  "  dental  ridge;"6.  you ng- 

,  -,  ,,        -I'l',!  •  o   •  1,  r»er  laver    of   epithelium :    c. 

brane,  beneath  which  is  the  ossifying  substance  of  deepest  layer  of  epithelium 
the  jaw — the  enamel  being  formed  from  the  epi-  —the  prismatic  or  columnar 

,11.  I'lpiiii         ij^i  1  j_'     stratum;  e.  enamel  germ. 

thelium  which  tills  the  dental  groove  and  consti- 
tutes the  rounded  projection  or  smooth  ridge,  and  the  dentine  and 
cementum  (crusta  petrosa)  from   the  deeper  structures  of  the  mucous 
membrane. 

Development  of  the  Enamel. — Fii'st,  as  to  the  development  of  the 
enamel.     About  the  sixth  or  seventh  week  of  foetal  life,  the  epithelium 

groove,  there  arises  isolated  and  uncovered  papillae  corresponding  In  number  to 
the  deciduous  teeth.  These  papilte  become  covered  in  by  the  deepening  of  the 
groove  and  the  coming  together  of  its  two  edges  over  their  tops,  while  at  the  same 
time  transverse  septa  are  formed,  so  that  the  several  papillse  become  enclosed  in 
separate  follicles. 


118 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


fills  the  groove  or  depression  on  the  surface  of  the  jaw  so  full  that  a 
small,  rounded  projection  or  ridge  is  formed,  from  the  under  surface  of 
which  a  process  sinks  into  the  tissue  beneath,  the  outlines  of  which 
resemble  in  shape  the  letter  V  with  the  apex  slightly  inclined  toward 
the  inner  surface  (Fig.  39).    This  epithelial  process  or  band  is  simply 

Fig.  39. 


a.  Flat  layer  of  epithelium ;  6.  proliferation  of  cuboidal  layer,  forcing  columnar. layer  downward, 
producing  V-shaped  appearance.  The  removal  of  these  upper  layers  leaves  the  "primitive  dental 
groove  " ;  c.  lamina  from  which  arise  the  epithelial  cords  of  enamel  organs. 

a  prolongation  of  the  natural  covering  of  the  mouth,  which  sinks  into 
the  embryonic  tissue  of  the  jaw,  and  forms  for  itself  a  groove  which  it 
completely  fills,  and  is  composed  of  the  same  histological  elements  as 
the  epithelium  of  the  mucous  membrane  of  the  mouth. 

When  this  epithelial  band  is  fully  formed  it  presents  two  surfaces, 
an  external  and  an  internal,  and  from  the  latter  a  process  is  given  off 
which  forms  the  epithelial  lamina.  This  epithelial  lamina  is  a  con- 
tinuous process  extending  over  the  entire  epithelial  band,  being  an 
inflexion  of  the  band  itself,  and  its  elements  are  the  same,  namely, 
polygonal  cells  inclosed  by  a  layer  of  prismatic  cells. 

The  "  dental  follicle  "  which,  as  av as  before  stated,  consists  of  the 

enamel  organ,  the  dentinal  germ  or 
papilla,  and  the  follicular  wall,  is 
developed  from  points  on  the  free 
extremity  of  the  epithelial  lamina. 
These    follicles    appear    as    small 
3     tubercles  arranged  at  intervals  on 
',      the  free  margin  of  the  lamina,  and 
'•      correspond  in  number  and  location 
I      to  the  future  deciduous  teeth,  being 
the  primitive  germs  of  the  dental 
follicles  which  retain  their  connec- 
tion with  the  lamina  by  means  of  a 
PRISMATIC  DENTAL  FOLLICLE.  slcuder  cord,  whlch  gradually  iu- 

c.  Prismatic  or  columnar  cells;  d.  large     creases  in  length  as  the  development 

polygonal  cell  of  the  epithelial  band;  e.  small 

cells  of  the  epithelial  lamina.  of  the  germ  at  its  extremity  i^ro- 


FiG.  40. 


ORIGIN   AND   FORMATION   OF   THE   TEETH. 


119 


gresses.  This  germ  constitutes  the  enamel  organ,  while  the  neck  or 
cord  in  its  progressive  lengthening  merely  serves  as  a  temporary  con- 
nection with  the  lamina.  This  germ  presents  a  spherical  form  in  its 
early  stage  (Fig.  40),  and  is  composed  of  an  external  layer  of  prismatic 
cells  (ameloblasts)  including  a  mass  of  j^olygonal  cells.  The  enamel 
organ  at  about  the  fourth  month  of  the  development  of  the  embryo 
has  undergone  very  considerable  changes,  the  primitive  polygonal 
cells  which  compose  the  central  mass  or  middle  region  of  this  organ 
have  been  transformed  into  stellate  bodies  differing  in  appearance 
from  the  primitive  cells,  a  process,  however,  which  is  confined  to  the 
cells  of  the  enamel  germ,  and  which  does  not  take  place  in  the  cells 
of  the  epithelial  cord  or  lamina,  thus  affording  evidence  that  the 
constitution  of  the  one  differs  from  that  of  the  other. 

These  stellate  cells  (Fig.  41)  are  composed  of  a  central  nucleus 
surrounded  by  a  transparent  or  finely  granular  mass,  which  mingles 
with  the  neighboring  elements. 


Fig.  41. 


Fig  42. 


STELLATE    CELLS    OF   THE    ENAMEL 
ORGAN. 

(Diagrammatic,  from  Frey.) 


Eepresents  the  hex- 
agonal form  assumed 
by  the  base  of  the  stel- 
late cells. 


They  occupy  at  first  only  the  centre  of  the  enamel  organ,  and  those 
near  the  periphery  preserve  their  primitive  polygonal  form,  but  be- 
come stellate  as  the  organ  increases  in  size,  and  are  formed  from  the 
original  elements  composing  the  internal  mass  of  the  enamel  organ, 
being  epithelial  in  their  nature. 

After  a  time  the  base  of  these  stellate  cells  presents  the  regular  pris- 
matic form  of  a  hexagon  (Fig.  42). 

During  this  modification  of  the  enamel  germ,  no  change  appears  to 
take  place  in  the  epithelial  lamina. 

The  primitive  enamel  germ  at  length  loses  its  original  spherical 
form,  and  becomes  somewhat  cylindrical,  pursuing  a  horizontal  course 
until  it  undergoes  a  considerable  increase  in  length,  when,  by  an 
abrupt  turn  it  takes  a  vertical  direction  and  sinks  into  the  tissues  of 
the  jaw. 


120 


PEINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


During  such  a  progress  the  cord  acquires  a  length  in  accordance 
"with  the  requirements  of  the  jaw. 

After  the  epithelial  cord  has  changed  its  course  from  a  horizontal 
to  a  vertical  direction,  its  extremity  expands  and  assumes  a  club-shape, 
on  account  of  the  multiplication  of  the  polyhedral  cells  of  which  its 
greater  portion  is  composed,  and  also  of  the  prismatic  cells  that  sur- 


FiG.  43. 


a^' 


a.  Epitlielial  laj'ers  of  mucous  membrane  lining  mouth ;  h.  embryonal  corpuscles  of  dermal  tissue 
of  jaw;  c.  budding  of  cord  of  permanent  tooth  from  cord  of  temporary  tooth;  d.  enamel  organ  of 
temporary  tooth;  e.  columnar  or  prismatic  layer  of  cells  from  which  ameloblasts  or  enamel  cells  are 
formed;  /.  dentine  germ  formed  from  embryonal  corpuscles  of  dermal  tissue;  g.  commencing  ossifi- 
cation of  inferior  maxilla;  h.  V-shaped  band,  resulting  from  proliferation  of  cells  of  cuboidal  layer; 
i.  development  of  connective-tissue  cells  from  embryonal  corpuscles,  forming  sac  which  incloses 
tooth-germ. 


round  it.  This  expanded  extremity  also  becomes  somewhat  spherical, 
and  its  upper  portion  corresponds  to  the  point  of  connection  with 
the  cord,  while  the  lower  portion  points  toward  the  base  of  the 
lower  jaw. 

This  condition  represents  a  fully  formed  enamel  organ,  which  is 
the  first  trace  of  the  dental  follicle.     Very  soon  the  lower  portion  of 


ORIGIN   AND   FORMATION   OF   THE   TEETH. 


121 


the  enamel  orgau  becomes  concave,  and  assumes  the  form  of  a  cap  or 
hood,  although  still  retaining  its  connection  with  the  epithelial  cord. 
At  this  stage  in  the  development  of  the  enamel  organ,  the  dentinal 
germ  or  papilla  makes  its  appearance. 

During  the  development  of  the  primitive  epithelial  cord,  lateral 
germs  similar  to  small  rounded  nodules,  in  the  form  of  varicosities, 
make  their  appearance,  and  which,  according  to  Magitot,  resemble 
an  irregular  chaplet  or  chain.  These  lateral  germs  are  composed  of 
small  polyhedral  cells,  like  those  of  the  cord  itself,  with  walls  formed 
of  a  layer  of  prismatic  cells  in  continuation  of  the  Malpighian  layer 
of  the  epithelium.  From  these  lateral  germs  or  masses,  at  a  later 
period,  after  the  cord  is  ruptured,  epithelial  prolongations  arise. 


^^>%^  'i'js&    Q- 


ENAMEL  ORGAN  AND  "  NAS.MVTH  S  LAYER 


■  OF  CELLS,  DRAWN  UNDER  A  MAGNIFVING  POWER  OF  ISOO 
DIAMETERS. 


a.  Portions  of  the  reticulum  which  lie  exactly  in  focus ;  the  points  of  intersection  are  seen  to  be 
made  up  of  a  finer  and  more  delicate  reticulum ;  5.  parts  which  lie  a  little  beyond  focus ;  c.  granu- 
lar matter  held  in  the  meshes  of  the  reticulum ;  d.  "  !Nasmyth'8  membrane,"  or  layer  of  flat  cells, 
just  outside  of  enamel  cells. 

The  primitive  cells  during  the  early  stage  of  evolution  present  the 
same  characteristics  on  all  parts  of  the  perij)hery,  but  as  soon  as  the 
dentinal  germ  or  papilla  begins  to  appear  these  primitive  cells  on  the 
concave  surface  lengthen,  while  those  of  the  convex  surface  decrease 
in  size  until  they  disappear  entirely,  before  the  atrophy  of  the  enamel 
pulp  ;  and  those  of  the  internal  surface  remain  for  the  formation  of 
the  enamel  organ. 

Besides  increasing  in  length,  the  prismatic  cells  of  the  concave  sur- 
face of  the  enamel  organ  undergo  changes,  their  extremities,  directed 
toward  the  centre  of  the  enamel  organ,  foi-ming  slender  processes, 
which  either  unite,  or  are  continuous  with  filaments  from  surrounding 


122 


PRINCIPLES    AND    PRACTICE   OF    DENTISTRY. 


Fig.  45. 


cells,  whicli  constitute  the  portion  of  the  enamel  organ  designated  as 
the  stratum  intermedium.  The  stratum  intermedium  consists  of  cells, 
which,  according  to  Mr.  Tomes,  are  intermedia,te  in  character  between 
those  of  the  bordering  epithelium  and  the  stellate  reticulum,  being 
branched,  but  less  conspicuously  so  than  the  stellate  cells,  with  which 
they  are  continuous  on  the  one  hand,  and  on  the  other  with  the  enamel 
cells.  According  to  Waldeyer,  Hertz  and  Hannover,  since  the  enamel 
cells  may  be  frequently  seen  connected  at  their  lower  extremities  with 
the  cells  of  the  stratum  intermedium,  a  multiplication  of  enamel  cells 
from  the  cells  of  this  stratum,  in  the  direction  of  their  length,  may  be 
admitted  to  occur. 

According  to  Dr.  G.  V.  Black,  and  quoted  by  Dr.  M.  A.  Dean, 
"just   before    the    calcification,    and    even    before    the    odontoblasts 

make  their  appearance,  the  ameloblasts 
(prismatic  cells),  and  the  tissues  of  the 
pulp  are  separated  by  a  well-marked 
double  pellucid  layer,  which  in  sections 
appears  as  a  double  band."  This  double 
band  is  represented  in  Fig.  45  by  the  two 
white  parallel  lines,  A  A,  the  upper  one 
being  the  tissue  which  is  identical  with 
the  membrana  prcefonnativa  of  Huxley, 
while  the  lower  one  represents  the  base- 
ment  membrane  of  Ladd  and  Bowman, 
and  the  membrana  prceformativa  of  Ras- 
chkow. 

After  the  epithelial  cells  are  changed 
into  hexagonal  prisms,  these  anastomose 
and  form  the  hexagonal  rods  character- 
istic of  fully  matured  enamel. 

The  epithelial  covering  on  the  outer 
surface  of  the  enamel  remains  distinctly 
perceptible,  and  after  the  eruption  of  the 
crown  of  the  tooth,  this  layer,  which  is 
known  as  the  "dental  cuticle" — cuticida 
dentis,  and  also  as  "  Nasmyth's  mem- 
brane," may  be  separated  from  the  enamel 
surface  beneath  it  by  strong  acids,  when 
the  hexagonal  depressions  of  enamel 
prisms  are  apparent,  and  on  the  applica- 
tion of  nitrate  of  silver  the  characteristics 
of  epithelium  appear. 
Dr.  I.  L.  Williams,  in  an  able  article  on  "  embryology,"  dissents 


B  M.  Basement  membrane ;  N.  neck ; 
S,  sac  or  follicular  wall ;  0.  enamel 
organ;  B.  bulb;  E  E.  external  epi- 
thelium of  the  enamel  organ  and  the 
basement  membrane  ;  E  0.  epithelial 
cord ;  C  T.  connective  tissue  surround- 
ing the  enamel  organ ;  Ep.  epidermis 
or  oral  epithelium. 

The  parts  embraced  between  the 
points  where  the  divergent  lines  A  A 
terminate  are :  (1)  The  concave  face  of 
the  enamel  organ,  lined  with  a  layer  of 
ameloblasts,  or  the  "internal  epithe- 
lium." (2)  The  membrana  praeforma- 
tiva  of  Huxley,  or  the  tissue  composed 
of  the  basal  coverings  of  the  amelo- 
blasts. (3)  The  membrana  praeforma- 
tiva  of  Raschkow,  or  the  basement 
membrane.  (4)  The  dentine  bulb  itself. 
Diagrammatic. 


ORIGIN   AND    FORMATION   OF   THE   TEETH. 


123 


from  the  opinion  of  Legros  and  Magitot  concerning  the  function  of 
the  membrana  prceformativa  of  Raschkow,  and  positively  denies  that 
it  has  any  modifying  influence  in  the  process  of  the  development  of 
the  teeth  ;  and,  while  he  is  not  prepared  to  deny  in  toto  the  existence 
of  this  membrane,  says,  that  an  examination  of  many  specimens  failed 
to  discover  this  structureless,  transparent  tissue ;  and  he  asks,  "  How 
is  it  possible  that  the  odontoblasts,  which  are  more  than  sij^j  of  an  inch 


Fig.  46. 


J.VW.JJsl 


THE  SPECIMEN  FEOM  WHICH  THIS  DRAWING  WAS  MADE  WAS  PLACED  TINDER  A  ONE-TENTH-INCH  IMMERSION 
LENS,  MAGNIFYING  ABOUT  800  DIAMETERS. 

a.  Connective  tissue  of  tooth-sac ;  6.  capillary  vessels  cut  transversely  and  longitudinally,  and 
filled  with  blood  corpuscles ;  c.  reticulum  of  enamel  organ ;  d.  round  and  flat  layer  of  cells,  forming 
the  so-called  "  Nasmyth's  membrane  ;"   e.  ameloblasts,  or  enamel  cells. 

in  diameter,  can  be  developed  in  a  membrane  which  Beale  says  is 
"  certainly  less  than  the  to^tto  of  an  inch  in  thickness."  Dr.  Williams 
also  remarks :  "  It  has  been  supposed  that  the  so-called  ameloblasts, 
or  enamel  cells,  are  formed  directly  from  the  layer  of  columnar  or 
prismatic  epithelium,  which  covers  the  face  of  the  enamel  organ." 
But  preceding  the  development  of  the  enamel  cells,  the  original  pris- 


124 


PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 


matic  cells  break  up  or  divide  into  round,  nucleated  corpuscles,  which 
change  is  denominated  by  Professor  Heitzmann  and  Dr.  Atkinson  a 
return  to  an  embryonal  condition." 

"  From  these  embryonal  corpuscles  are  developed  the  enamel-forming 


Fia.  47. 


DRAWN  UNDEE  THE  SAME  MAGNIFYING  POWER  AS  FIG.  46. 

a.  Connective-tissue  cells  of  tooth-sac ;  6.  reticulum  of  enamel  organ.  In  this  drawing  it  is  seen 
that  the  reticulum  holds  in  its  meshes  very  large,  soft,  granular  corpuscles,  heretofore  known  as  the 
gelatinous  fluid  of  the  enamel  organ;  c.  breaking  down  of  columnar  layer  of  cells  into  embryonal 
corpuscles,  from  which  ameloblasts  are  developed. 


ORIGIX   AND   FORMATION   OF   THE   TEETH.  125 

cells,  and  also  an  outer  layer  of  smaller  cells,  from  which  is  formed 
Nasmyth's  membrane." 

The  same  author  also  regards  the  enamel  organ  as  a  "true  secretinc 
organ,"  and  that  the  material  for  the  formation  of  enamel  has  no  other 
evident  source. 

Development  of  the  Dentine. — As  the  epithelium  is  undergoing  this 
peculiar  development  into  the  enamel  organ,  a  projection  of  the  corium 
of  the  mucous  membrane  of  the  foetal  jaw  rises  up  to  meet  it  out  of  the 
dental  groove.  This  projection  is  the  dentinal  papilla  or  germ,  which 
is  described,  after  Dursy  and  Waldeyer  as  a  ridge,  "  the  intervening 

Fig.  48. 


?-t 


^c  \^ 


a.  Meckers  cartilage ;  &,  traces  of  ossification  ;  c.  lowest  layer  of  Malpighian  stratum ;  d.  oral 
epithelium ;  F.  ameloblastic  or  prismatic  layer ;  loner  F.  external  layer  of  enamel  organ  ;  g.  stellate 
reticulum  of  the  enamel-organ;  B.  dental  germ  or  papilla;  I.  follicular  walls. 

parts  of  which  are  atrophied  so  as  to  leave  papillse  or  germs  which  be- 
come coated  all  over  by  the  enamel  organ,  and  thus  the  saccular  stage  of 
the  teeth  is  produced,  the  papillfs  which  are  to  form  the  bulk  of  the 
teeth  being  coated  with  a  vascular  connective  tissue,  isolated  by  the 
enamel  organ  and  separated  from  each  other  by  the  growing  (osseous) 
tissue  of  the  foetal  jaw." 

Dursy,  according  to  Waldeyer,  says :  "  The  first  germ  of  the  dentine 
appears  in  the  dental  sacculus,  as  a  dark  semi-lunar  area  at  the  bottom 
of  the  dental  groove — that  is  to  say  of  the  enamel  germ— coetaueously 
and  continuously  with  which  it  is  developed  along  each  half  of  the  jaw.^ 


126 


peijStciples  and  practice  of  dentistry. 


At  certain  points  corresponding  to  the  position  of  the  subsequent  teeth, 
the  young  structure  develops  in  the  form  of  papillae,  projecting  against 
the  enamel  germs,  while  the  remainder  atrophies.  The  two  horns  of 
the  semi-lunar  mass  (as  seen  in  section)  extend  from  the  base  of  the 
dental  papilla  some  distance  upward,  and  embrace  the  dentine  germ 
and  enamel  organ." 

As  the  dentinal  papilla  or  germ  increases  in  height,  it  assumes  a 
slightly  oblique  direction  in  relation  to  the  axis  of  the  follicle,  and  at 
the  same  time  becomes  constricted  at  its  base,  thus  forming  a  neck  at 
the  line  where  the  enamel  organ  is  reflected  back  upon  itself  (Fig.  48.) 
The  follicular  wall,  which  forms  a  part  of  the  dental  follicle,  first 
appears  as  a  process  arising  from  the  base  oi  the  papilla,  to  the  neck 
of  which  it  is  attached  like  a  slight  collar.  Its  development  begins 
as  soon  as  the  small  mass  which  constitutes  the  dentinal  germ  assumes 
§.  hemispheric  form.  The  follicular  wall,  by  its  gradual  upward 
growth,  at  length  embraces  and  isolates  both  the  enamel  organ  and 
the  dentinal  papilla,  and  during  its  evolution,  from  being  composed 
of  embryoplastic  elements,  by  degrees  assumes  the  appearance  of  a 
distinct  laminated  membrane,  which  may  be  separated  from  the 
adjacent  tissue,  except  at  the  base  of  the  papilla  to  which  it  remains 
adherent.     According  to  both  Kolliker  and  Huxley,  the  transparent 

stratum  (viembrana  prceforma- 
tiva)  which  invests  the  dentinal 
papilla  reflects  itself  back  on  its 
internal  surface,  and  thus  lines 
the  whole  inner  surface  of  the 
follicular  wall. 

As  the  evolution  of  the  folli- 
cular wall  progresses,  it  closes 
over  the  contents  of  the  dental 
follicle,  which,  besides  the  wall, 
consist  of  the  enamel  organ  and 
the  dentinal  jDapilla;  the  enamel 
organ  being  subjacent  to  the 
follicular  wall,  to  which  it  con- 
forms in  such  a  manner  that, 
while  the  external  face  of  the 
organ  is  in  relation  with  the 
wall,  the  lower  concave  face  is 

a.  Wall  of  the  sac,   ormed  of  connective  tissue,  with  j^    inj^^ediate    COUtact    with     the 
Its  outer  stratum  a'-  and  its  inner  a^  ;  o.  enamel  organ, 

with  its  papillary  and  parietal  layer  of  cells;  c.d.  the  papilla.       The      dentinal     papilla 

enamel  membraneandenamel  prisms:  e.  dentine  cells;  QgcupieS  the  loWCr  and  central 
/.  dental  germ  and  capillaries;  g.  i.  transition  of  the  _ 

wall  of  the  follicle  into  the  tissue  of  the  dental  germ,  portion  of  the  follicular  SaC. 


Fig.  49. 


OKIGIN    AND    FOEMATION    OF   THE    TEETH.  127 

The  enamel  organ  fills  the  entire  space  between  the  sac  wall  and 
the  papilla,  terminating  at  the  base  of  the  latter  in  a  rounded  margin 
which  forms  the  dividing  line  between  the  prismatic  cells  which  cover 
its  concave  and  convex  surfaces  (Fig.  49).  The  dental  follicle  is  of 
an  ovoid  form,  and  varies  in  size  according  to  the  class  of  tooth  to  be 
developed  from  it;  and  when  it  is  completely  formed,  it  remains 
inclosed  within  the  embryonal  tissues  of  the  jaws,  with  which  it  is  at 
first  only  slightly  connected. 

When  the  rupture  of  the  epithelial  cord  occurs,  it  loses  its  com- 
munication with  the  mucous  membrane,  and  forms  no  connection  with 
the  maxillary  bone,  as  the  alveolar  processes  are  not  developed  until 
a  later  period. 

The  rupture  of  the  epithelial  cord,  which  brings  about  the  isolation 
of  the  dental  follicle  from  the  mucous  membrane,  is  due  to  the  upward 
growth  of  the  follicular  wall,  which  closes  over  the  top  of  the  enamel 
organ,  beneath  which  is  the  papilla,  the  union  of  the  edges  of  the  wall 
producing  compression  or  strangulation  of  the  cord  at  that  point.  At 
this  period  of  evolution,  the  saccular  stage,  the  dental  follicle  is  com- 
pleted, and  from  the  cells  of  the  dentinal  papilla  a  soft  matrix  of 
animal  matter  is  formed,  which  becomes  impregnated  with  calcareous 
matter  to  form  the  complete  dentinal  tissue,  while  in  the  interior  of 
the  cavity  of  the  dentine,  cells  are  formed,  which  continue  to  form  new 
matrix  for  a  considerable  time. 

.  After  the  dentinal  papilla  has  become  coated  over  by  the  enamel 
organ,  and  the  saccular  stage  of  the  teeth  is  produced,  and  the  papillse 
have  become  separated  from  each  other  by  the  developing  tissue  of  the 
embryonic  jaw,  odontoblasts  (dentine  cells)  begin  to  form.  These 
odontoblasts  are  large  nucleated  cells  of  elongated  form,  containing 
numerous  processes  developed  from  the  cells  of  the  dentinal  papilla, 
which  at  that  early  period  consist  of  fine  fibrous  tissue  with  numerous 
cells. 

The  odontoblasts  send  out  processes  which,  as  they  develop,  calcify 
extei-nally,  the  calcified  portion  forming  the  dentine,  and  the  uncalci- 
fied  part  the  dentinal  fibrillse,  and  the  lateral  branches  of  anastomosis 
whereby  the  tubuli  or  canals  of  the  dentine  anastomose.  The  remains 
of  the  odontoblasts  form  a  cellular  layer  which  constitutes  the  invest- 
ment of  the  pulp  lying  between  its  nerves  and  vessels  and  the  dentine. 
This  cellular  layer  is  known  as  the  "ivory  membrane" — memhrana 
eboris  of  Kolliker. 

The  enamel  organ  is  non-vascular,  but  a  network  of  vessels  is  fur- 
nished to  the  follicular  wall  and  the  dentinal  papilla  from  the  sur- 
rounding tissues. 

At  the  period  when  the  epithelial  cord  is  ruptured,  the  cells  com- 


128  PRINCIPLES    AND    PRACTICE   OF   DENTISTRY. 

posing  the  epithelial  lamina  become  greatly  increased  in  number,  and 
irregular  proliferations  or  "  buddings"  occur,  which  wander  by  different 
courses  into  the  deeper  portions  of  the  embryonal  tissue.  These 
buddings  differ  in  form,  sometimes  in  that  of  cylinders  which  retain 
their  connection  with  the  primitive  lamina ;  but  frequently  this  con- 
nection is  absorbed,  and  an  epithelial  mass  is  set  free.  Clusters  of 
these  masses  occasionally  take  the  globular  form,  resembling  those  in 
the  lamina  itself,  but  frequently  they  become  absorbed  and  disappear 
before  the  development  of  the  tooth  is  completed.  At  the  time  the 
absorption  of  the  epithelial  lamina  is  taking  place,  changes  precisely 
analogous  are  transpiring  in  the  severed  epithelial  cord. 

Fig.  50. 


ffUilTiLiL 


o.  Meckel's  cartilage;  b.  traces  uf  ussificatlon;  c.  lowest  layer  of  Malpighian  stratum;  d.  oral 
epitlielium ;  F.  ameloblastic  layer ;  lower  F.  external  layer  of  enamel  organ ;  H.  dentinal  papilla ;  /. 
follicular  wall ;  K.  buddings  of  epithelial  cord. 

From  the  remains  of  this  cord  processes  are  given  off,  which  at 
times  become  quite  numerous,  and  may  remain  almost  to  the  time  of 
the  eruptive  stage  of  the  tooth. 

The  direction  of  these  processes  is  toward  the  epithelium,  and  they 
consist  of  the  same  polyhedral  cells  as  the  cord  and  lamina,  but  are 
never  invested  with  prismatic  cells.  All  these  epithelial  proliferations 
finally  disappear  by  absorption,  unless  some  such  masses  may  become 
detached  and  wander  into  the  deeper  tissues ;  for  it  is  conceded  by 
some  eminent  histologists  that  a  dentinal  papilla  or  germ  may  originate 


ORIGIN   AND    FORMATION   OF   THE   TEETH. 


129 


from  any  point  of  the  dentinal  sheet  of  tissue  with  which  the  epithelial 
mass  comes  in  contact,  and  that  it  is  solely  through  the  influence  of  the 
enamel  organ  upon  this  tissue  that  the  development  of  the  dentinal 
papilla  is  induced. 

Immediately  after  the  rupture  of  the  epithelial  cord,  the  formation 
of  the  secondary  follicle  of  the  permaiient  tooth  begins.  There  is  no 
trace  of  the  osseous  tissue  of  the  jaw  at  the  time  of  the  origin  of  the 
primitive  epithelial  cord.  Bone  first  makes  its  appearance  hear  the 
base  of  the  follicles,  forming  a  horizontal  layer,  and  separating  the 
groove  of  the  follicles  from  the  canal  reserved  for  the  vessels  and  nerves. 
From  the  layer  or  floor,  lateral  processes  arise  and  form  the  dental 
groove,  in  which  the  follicles  remain  for  some  time  without  being  sepa- 


FROM  THE  UPPER  JAW  OF  A  KITTEN,  ABOUT  THE  TIME  OF  IIIRTH. 

o.  Oral  epithelium  ;  6.  bone  of  jaw;  c.  neck  of  enamel  organ;  d.  dentinal  papilla;  e.  enamel  cells; 
/.  stellate  reticulum;  h.  germ  or  papilla  of  permanent  tooth,  the  enamel  organ  of  which  is  derived 
from  the  primary  cord. 


rated  by  transverse  partitions,  and  it  is  only  after  the  development  of 
the  crowns  of  the  teeth  has  commenced,  that  bony  processes  are  thrown 
across  the  groove,  forming  receptacles  for  the  lodgment  of  each  follicle 
with  an  opening  in  the  direction  of  the  epithelial  surface  (Fig.  51). 

Development  of  Cementum  (  Crusta  Petrosa). — There  appears  to  be  a 
difference  of  opinion  among  histologists  concerning  the  origin  of  the 
cementum.  Magitot,  in  1858,  and  again  Robin  and  Magitot,  in  1861, 
described  a  new  tissue,  which,  some  time  before  the  formation  of  the 
first  dentine  cap,  was  supposed  to  exist  between  the  follicular  wall  and 
the  organs  within  it — the  enamel  organ  and  the  papilla — differing  from 
the  other  tissues  in  coloi',  consistence  and  structure,  and  upon  which 
the  formation  of  the  cementum  depended. 

9 


130 


PRINCIPLES   AXD    PRACTICE    OF    DENTISTRY. 


Fig.  52. 


---    d 


On  the  other  hand,  Kolliker,  Waldeyer,  Hertz,  Kollman,  and  others, 
deny  the  existence  of  such  a  membrane  or  tissue,  and  ascribe  the  for- 
mation of  the  cementum  (which  resembles  ordinary  bone,  as  it  contains 
canaliculi  and  lacunae),  to  a  periosteal  origin — that  it  is  developed  from 
the  deeper  tissues  of  the  foetal  jaw  by  periosteal  ossification,  the  process 
being  similar  to  that  of  bone  formation  in  other  parts  of  the  body. 

Origin  of  the  Permanent  Teeth. — While  Goodsir  held  that  the  folli- 
cles of  the  permanent  teeth  originate  from  a  fold  of  the  sac  of  the 
primitive  or  deciduous  follicle,  the  later  investigations  of  Kolliker  and 
Waldeyer  have  shown  that  the  permanent  follicles  of  teeth  that  have 
deciduous  predecessors  arise  from  certain  prolongations  of  the  primi- 
tive epithelial  cord. 

The  germ  of  the  permanent  follicle  originates  at  a  point  where  the 
primitive  epithelial  cord  merges  into  the  enamel  organ  of  the  tem- 
porary tooth,  and  is  an  outgrowth  of  this  cord  (see  Fig.  52).  The 
permanent  cord  takes  a  vertical  direction,  and  passes  between  the 

bony  alveolar  wall  and  the 
primitive  follicle,  and  then 
along  the  inner  or  lingual  face 
of  the  follicle,  its  elements 
being  the  same  as  those  of  the 
primitive  cord. 

The  permanent  dentinal 
papilla  or  germ  sinks  to  the 
bottom  of  the  osseous  dental 
groove,  where  it  soon  loses  its 
connection  with  the  primitive 
follicle,  though  still  retaining 
its  relation  with  the  epithelial 
lamina. 

The  primitive  follicle,  how- 
ever, by  the  severance  of  its 
cord  at  a  point  just  below  where 
the  germ  of  the  permanent  or 
secondary  cord  arises,  loses  all 
connection  with  the  epithelial 
lamina,  and  develops  as  an  in- 
dependent body  or  organ. 
The  sinking  of  the  follicle 

point  where  Its  separation  from  the  primitive  cord  is  ^f  ^^^  permanent  tOOth  is  SOOU 

being  effected;    a.  Meckel's  cartilage  diminished  by  „  „            ,    ,          ,             ^.               •           n 

;ibsorption;   b.  bone  of  the  jaw;   c.  (upper)  dental  ar-  foliowed    by  the  entire  SOrieS  Ot 

tery,  (lower)  dental  nerve ;  d.  epithelium  :  E.  originally  phenomena  which   characterize 

the  cord  of  the   temporary  follicle,  but  now  the  sole  ^^          p                       ^       4.    ^ 

.property  of  the  pei-manent  one.  the      grOWth     of     OVery     dental 


SECTION  OF  THE  LOWER  JAW  Or  A  HUMAN  FffiTUS. 

\    inches    in    length;    corresponding    to   about   the 
eighteenth  week.    (Magnified  80  diam.) 
K   Cord  or  bourgeon  of  the  secondary  follicle;   L. 


ORIGIN   AKD    FORMATION   OF   THE   TEETH.  131 

follicle ;  and  while  the  permanent  follicle  is  being  developed,  the 
remains  of  the  ruptured  primitive  cord  which  continues  to  be  attached 
to  the  primitive  follicle,  are  subject  to  that  "  budding  "  process  which 
invariably  commences  at  the  moment  this  cord  is  severed — about 
the  fourth  mouth,  or  quickening  period.  The  direction  of  the 
permanent  cord  being  vertical,  its  length  is  governed  by  the  height 
of  the  alveolar  border,  and  the  direction  of  the  primitive  follicle. 
When  sinking  into  the  substance  of  the  jaw,  the  permanent  cord 

Fig.  53. 


VERTICAL   SECTION    OF   THE   LOWER  JAW    OF   A   HUMAN    FCETDS, 

Measuring  18^  inches;  corresponding  to  nearly  the  thirty-ninth  week  of  gestation.  The  figure 
represents  a  cut  passing  through  the  follicle  of  a  bicuspid. 

6.  Bone  of  the  jaw ;  d.  oral  epithelium  ;  g.  enamel  organ ;  B.  dental  bulb ;  K.  dibris  of  the  cord  of  a 
permanent  follicle ;  E'  K'.  epidermal  globules.  Follicle  for  the  permanent  tooth  connected  with  tJie 
dibris  of  its  cord,  K. 

always  assumes  a  spiral  form,  and  to  such  a  degree  that  it  can  be 
readily  distinguished  from  the  primitive  cord,  as  this  latter  is  never  so 
distinctly  spii-al  in  form  as  the  former. 

This  spirality  of  form  peculiar  to  the  permanent  cord  is  occasioned 
by  the  greater  distance  this  cord  must  traverse  in  the  more  developed 
tissues  of  the  jaw,  to  permit  the  permanent  follicle  to  accomplish  its 
passage  to  a  point  under  the  temporary  tooth,  and  thus  prevent  the 


132  PRINCIPLES    AND    PRACTICE    OF    DENTISTRY. 

stretching  of  the  cord  and  the  disturbance  of  the  parts  with  which 
the  cord  and  enamel  organ  are  connected.  The  spiral  nature  of  the 
cord  continues  from  its  origin  towards  its  termination  in  a  rounded 
or  club-shaped  enlargement,  similar  to  that  of  the  extremity  of  the 
primitive  cord,  this  enlargement  representing  the  enamel  organ  of  the 
permanent  tooth. 

At  the  period  in  the  evolution  of  the  permanent  follicle  when  the 
dentinal  papilla  becomes  unicuspid  for  the  incisors  and  canines,  and 
multicuspid  for  the  molars,  the  permanent  epithelial  cord,  which  has 
already  been  for 'some  time  severed  from  the  primitive  cord  and 
follicle,  also  loses  its  connection  with  the  permanent  follicle,  and  has 
no  communication  afterwards  with  the  epithelial  lamina.  This  sever- 
ance is  soon  followed  by  the  separation  of  the  permanent  cord  into 
fragments,  which,  as  was  before  stated,  bud  and  lengthen  in  different 
directions,  and  become  mingled  and  confounded  with  those  of  the 
primitive  cord,  anastomosing  with  them  to  form  a  sort  of  plexus. 
Finally,  all  these  epithelial  masses  atrophy  and  disappear. 

The  above  description  app)lies  to  the  development  of  the  permanent 
teeth  that  have  temporary  predecessors.  But  the  origin  of  the  perma- 
nent teeth  that  appear  back  of  the  temporary  teeth,  and  have  no 
deciduous  predecessors,  is  entirely  different. 

The  first  permanent  molar,  the  follicle  of  which  makes  its  appearance 
during  the  fifteenth  week  of  embryonal  life,  and  only  a  few  days  after 
the  greater  number  of  those  of  the  deciduous  teeth,  and  yet  does  not 
erupt  until  about  the  sixth  year,  originates  directly  from  the  epithelium 
of  the  mucous  membrane,  the  epithelial  cord  from  which  penetrates 
the  foetal  tissue  in  a  region  where  no  follicle  has  preceded  it. 

The  second  permanent  molar  originates  from  an  outgrowth  of  the 
epithelial  cord  of  the  follicle  of  the  first  permanent  molar,  resembling 
in  this  respect  the  twenty  anterior  permanent  teeth,  but  differing  in  the 
direction  of  its  course.  While  the  teeth  derived  from  the  temporary 
follicles  pass  over  the  lingual  face  of  the  latter  to  a  position  beneath 
them,  that  of  the  second  permanent  molar  takes  a  horizontal  direction 
for  some  distance,  and  then  by  an  inflection  takes  its  position  at  the 
posterior  side  of  the  follicle  of  the  first  molar,  where  it  is  developed  in 
a  line  with  those  anterior  to  it  TFig.  54). 

The  origin  of  the  third  molar  or  wisdom  tooth  is  effected  in  the  same 
manner  as  that  of  the  second  permanent  molar,  as  the  epithelial  cord 
that  forms  its  enamel  organ  emanates  from  the  cord  of  the  second 
permanent  molar.  Hence  we  find  the  cord  of  the  first  permanent 
molar  originating  from  the  epithelium  ;  that  of  the  second  permanent 
molar  from  the  cord  of  the  first  permanent  molar ;  and  that  of  the 
third  molar  from  the  cord  of  the  second  permanent  molar. 


OEIGIX   AND    FORMATION  OF   THE   TEETH.  133 

Dr.  G.  V.  Black,  whose  extensive  researches  in  dental  histology  are 
worthy  of  all  praise,  is  of  the  opinion  that,  "  although  the  epithelial 
cords  of  the  twenty  anterior  permanent  teeth  generally  arise  from 
those  of  the  temporary  follicles,  yet  they  do  sometimes  emanate 
directly  from  the  epithelium  of  the  mucous  membrane. 

If  such  is  the  case,  the  secondary  or  permanent  epithelial  cords  may 
originate  from  either  the  primary  cord,  the  temporary  follicle,  or  the 
epithelial  lamina.  The  follicles  of  the  temporary  teeth  are  developed 
during  the  period  between  the  latter  part  of  the  third  month  of  gesta- 

FiG.  54. 


SECTION   ON   A   LINE   'WITH   THE   FOLLICLE    OF   THE   FIRST   PERMANENT   MOLAB. 

Human  subject,  three  months  after  birth.     Magnified  80  diameters. 
6.  Maxillarj'  bone;  c.  c.  dental  artery  and  nerve;  E.  cord  of  the  follicle  of  the  first  permanent 
molar;  g.  enamel  organ;  R.  bulb  of  the  first  permanent  molar;  E.  bourgeon  of  the  enamel  organ  of 
the  second  permanent  molar. 

tion  and  the  beginning  of  the  fourth  year — within  forty-two  months, 
while  the  follicles  of  the  permanent  teeth  require  a  much  longer  time 
for  their  evolution,  it  would  seem  quite  reasonable  to  suppose  that 
the  dentinal  papilla  acts  as  an  organic  mould  upon  which  the  elements 
of  the  enamel  are  coated,  but  Magitot  asserts  that  as  the  epithelial  cord 
which  represents  the  future  enamel  organ  always  precedes  the  appear- 
ance of  the  papilla,  which  is  never  formed  until  the  cord  has  advanced 
a  certain  distance,  this  cord  decides  not  only  the  place  of  genesis,  but 
the  form   and  function   of  the  corresponding  tooth.      According  to 


134 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


Dursy,  a  dentine  germ  or  papilla  may  be  developed  from  any  point 
of  the  semi-lunar  area  which  is  found  below  the  enamel  organ, 
as  soon  as  such  a  point  is  reached  by  this  organ,  and  the  den- 
tine germ  depends  upon  the  course  which  the  enamel  organ  takes. 
For  example,  if  the  epithelial  cord  of  a  canine  should  take  an  unnat- 
ural course,  so  as  to  come  in  contact  with  the  dentinal  tissue  at  a  point 
between  the  bicuspids,  the  canine  would  be  developed  between  those 
teeth ;  hence  it  seems  reasonable  to  conclude  that  the  enamel  organ 
determines  the  form  and  character  of  the  future  tooth. 

Although  the  proliferations  or  buddings  of  the  remains  of  the  epi- 
thelial cord,  after  its  severance  from  the  enamel  organ,  usually  disap- 
pear by  absorption,  yet  it  is  possible  that  some  such  masses,  meeting 
with  dentinal  tissue,  may  become  the  enamel  organs  of  supernumerary 
teeth. 

THE   DENTAL   PULP. 

The  pulp,  occupying  the  pulp  cavity  in  the  centre  of  the  tooth,  is 
the  shrunken  condition  to  which  the  tooth-germ,  or  dentinal  papilla, 


Fig.  56. 


A  PORTION  OF  THE  BODY  OF  THF,  PULP,  SHOWING  THE 
CELLL'LAE  ARRANGEMENT. 


A  PORTION  OF   THE   SUPERFICIAL   LAYER   OF  THE 
PULP,  SHOWING  THE  APPEARANCE  OF  VESICLES.  ' 


is  permanently  reduced  after  it  has  normally  accomplished  the  work 
of  dentiuification,  and  affords  the  vascular  and  nervous  supply  of  the 
dentine.  It  is  an  exquisitely  sensitive,  highly  vascular  substance,  of 
a  reddish-gray  color,  enveloped  in  an  exceedingly  delicate  and  appa- 
rently structureless  membrane,  continuous  with  the  alveolo-dental 
periosteum,  and  adherent  to  the  walls  of  the  pulp  cavity.  This  is 
designated  by  Mr.  Thomas  Bell  "  the  proper  membrane  of  the  pulp," 
and  by  Purkinje  and  Raschkow,  "  the  preformative  membrane ;" 
because,  in  the  formation  of  the  dentine,  the  deposition  of  earthy  salts, 
according  to  these  authors,  commences  in  it. 

The  pulp,  according  to  the  two  last-mentioned  authors,  is  composed 
of  minute  globules.  Schwann  describes  it  as  consisting  of  globular, 
nucleated  cells,  with  vessels  and  nerves  passing  between  them,  the  cells 


THE   DENTAL   PULP. 


135 


having  the  same  radical  course  as  the  fibres  of  the  dentine.  According 
to  the^nicroscopic  observations  of  Mr.  Nasmyth,  it  is  principally  com- 
posed of  minute  vesicular  cells,  varying  in  size  from  the  ten- thousandth 


Fig   57. 


a.  The  vessels  of  the  pulp  ot  au  upper  central  incisor  injected,  as  seen  under  the  microscope,  very 
highly  magnified;  b.  the  natural  size  of  the  pulp. 

to  the  one-eighth  of  an  inch  in  diameter,  disposed  in  concentric  layers; 
these,  when  macerated,  have  an  irregular,  reticulated  appearance,  and 
are  found  to  be  interspersed  with  granules,  the  parenchyma  being 


136 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


Fig, 


traversed  by  vessels  having  a  vertical  direction.     See  Figs.  55  and  56, 
copied  from  Mr.  Nasmyth. 

Mr.  Tomes  describes  it  as  consisting,  from  its  earliest  ajopearance,  of 
a  series  of  nucleated  cells,  united  and  supported  by  plasma;  also,  prior 
to  the  commencement  of  the  formation  of  the  dentine,  of  delicate 
areolar  tissue,  occupied  by  a  thick,  clear,  homogeneous  fluid  or  plasma. 
The  pulp  is  liberally  supplied  with  blood  vessels,  furnished  by  the 
trunk  which  enters  its  base.  The  ramifications  of  these  vessels  are 
distributed  throughout  its  entire  substance,  forming  a  capillary  net- 
work which  terminates  in  loops  upon  its  surface. 

Three  or  more  arteries  enter  at  the  apicial  foramen,  and  supply  the 
pulp,  dividing  into  branches,  which,  after  pursuing  a  parallel  course, 
form  a  capillary  plexus,  immediately  beneath  the  cells  of  the  memhrana 
eboris,  or  ivory  membrane.  The  nerves  of  the  pulp  enter  the  apicial 
foramen  by  one  large  and  three  small  trunks,  and,  like  the  arteries, 
pursue  at  first  a  parallel  course,  and  then  form  in  the  bulb  a  rich 
plexus  beneath  the  membrana  eboris.     The  nature  of  the  terminations 

of  the  nerve  fibres  in  the  pulp  is  yet  un- 
certain. Magitot  states  that  he  has  fully 
satisfied  himself  that  the  nerves  become 
continuous  with  the  branched,  somewhat 
stellate  cells,  which  form  a  layer  beneath 
the  odontoblasts,  and,  through  the  medium 
of  these  cells,  with  the  odontoblasts  them- 
selves. Concerning  this,  Mr.  Charles 
Tomes  remarks :  "  If  this  view  of  their 
relation  to  the  nerves  be  correct,  the 
sensitiveness  of  the  dentine  would  be 
fully  accounted  for  without  the  necessity 
for  the  supposition  that  actual  nerve 
fibres  enter  it,  for  the  dentinal  fibrils 
would  be,  in  a  measure,  themselves  pro- 
longations of  the  nerves." 

The"  distribution  of  the  vessels  of  the 
pulp  is  represented  in  Fig.  57,  copied 
from  the  work  of  Mr.  Nasmyth,  and  made 
from  an  injected  preparation  of  an  upper 
central  incisor.  The  communication  of  the 
arteries  with  the  veins  by  means  of  a  series 
of  looped  capillaries,  presenting  a  densely 
matted  appearance  upon  the  surface,  is 
THE  NERVES  OF  THE  PULP  OF  AN  bcautifully  rcprescnted.  The  nerves  of 
tTentv  B^'METERr''"'  "^<^"'^"^"     thc  pulp  havc  a  vcry  similar  arrangement 


TOOTH   STRUCTURES.  137 

ft 

in  their  distribution,  having  apparently  looped  terminations  (Fig.  58). 
Kolliker  describes  the  pulp  as  consisting  of  an  indistinctly  fibrous 
connective  tissue,  containing  many  dispersed,  rounded  and  elongated 
nuclei,  with,  occasionally,  narrow  bundles  somewhat  like  imperfect 
foetal  connective  tissue  filled  with  a  fluid  substance.  Immediately 
beneath  the  structureless  membrane  in  which  these  tissues  are  en- 
closed, there  is  a  layer  composed  of  many  series  of  cells,  cylindrical  or 
pointed  at  one  end,  with  long  and  narrow  nuclei,  arranged  perpendicu- 
larly to  the  surface  of  the  pulp,  like  a  cylinder  of  epithelium.  This 
layer  is  described  as  being  from  two  to  four  one-hundredths  of  a  line 
in  thickness.  These,  in  regular  series  proceeding  internally,  become 
less  and  less  distinct ;  "  but  the  cells,  without  losing  their  radial 
arrangement,  are  more  intermixed,  and  pass  finally,  by  shorter  and 
rounder  cells,  without  any  sharp  line  of  demarcation,  into  the  vascular 
tissue  of  the  pulp."  His  description  of  the  distribution  of  the  vessels 
and  nerves  of  the  pulp  is  similar  to  that  given  by  Mr.  ISTasmyth  and 
Mr.  Tomes. 

The  dental  pulp  undergoes  considerable  change  in  advanced  age, 
diminishing  in  size  by  its  progressive  calcification. 

Further  degeneration  shows  an  atrophied  condition  of  the  odonto- 
blastic layer,  and  coincidently  with  the  diminution  in  the  quantity  of 
the  cellular  elements,  an  increase  of  the  fibrillar  connective  tissue.  At 
last  the  capillary  system  becomes  obliterated,  according  to  Mr.  Charles 
Tomes,  "  by  the  occurrence  of  thrombosis  (eff'usion  of  blood  into  the 
cellular  substance)  in  the  larger  vessels,  the  nerves  undergo  fatty  de- 
generation, and  the  pulp  becomes  a  shriveled,  unvascular,  insensitive 
mass." 


CHAPTER  XI. 

TOOTH   STRUCTURES. 


ENAMEL. — With  regard  to  the  formation  of  the  enamel,  the  dental 
follicles  have  their  origin  in  a  cord  which  emanates  from  the  epi- 
thelial layer  of  the  mucous  membrane  of  the  mouth.  These  cords  arise 
directly  from  a  process  of  the  oral  epithelium,  those  of  the  permanent 
teeth,  which  succeed  the  deciduous  ones,  being  outgrowths  from  the 
primitive  cords.  Concerning  the  cords  of  the  other  permanent  teeth, 
those  for  the  first  molars  origitiate  directly  from  the  epithelium  of  the 
mucous  membrane,  and  the  remaining  ones  from  the  cords  of  the  pre- 
ceding molars.     The  enlarged  extremity  of  the  cord  constitutes  the 


138 


PRINCIPLES   Am)   PRACTICE   OF   DENTISTRY. 


enamel  organ  of  the  future  dental  follicle.     (See  Origin  and  Formation 
of  the  Teeth.) 

When  the  enamel  is  first  deposited  upon  the  surface  of  the  dentinal 
papilla,  it  is  of  a  chalky  appearance,  and  afterward  attains  the  glossy- 
hardness  by  which  it  is  characterized,  with  a  white  appearance,  like 
porcelain. 


Fig.  59. 


Fig.  60. 


A  SIDE  VIEW  OF  THE  KNAMF.T.  FIBRES  ; 
NIFIED   800   TIMES. 


1.  The  enamel  fibres  :  2  2.  transverse  striae 
upon  them. 


THE  HEXAGO>'.\L  TERMINA- 
TIONS OF  THE  FIBRES  OF  A 
PORTION  OP  THE  SURFACE  OF 
THE  ENAMEL;  HIGHLY  MAG- 
NIFIED. 

At  1,  2,  3,  the  crooked 
crevices  between  the  hexag- 
onal fibres  are  more  strongly 
marked. 


The  enamel  forms  a  smooth,  dense  layer,  en- 
veloping the  crown  of  the  tooth  as  far  as  the 
neck,  where  it  insinuates  itself  between  the 
cementum  and  dentine.  It  is  thickest  on  the 
cutting  edges  and  grinding  surfaces  of  the  teeth, 
tapering  to  a  thin  edge  at  their  necks.  In  color 
it  is  rather  translucent  than  white.  The  analysis  of  enamel  con- 
sists of — 


Calcium  Phosphate, 85  3 

Calcium  Carbonate,      .         .         .         .         •         .         .         .8.0 

Calcium  Fluoride, 3.2 

Magnesium  Phosphate, 1.5 

Sodium  Salts, 1-0 

Animal  Matter  and  Water, •       1.0 


Von  Bibra  gives  the  following  : — 

Adult 
Man. 
Calcium  Phosphate  and  Fluoride,         .         .         .     89.82 
Calcium  Carbonate,      .         .         .         ,         .         .4.37 

Magnesium  Phosphate, 1.34 

Other  salts, 88 

Cartilage, 3.39 

Fat, .  -20 

Organic,       .         .         .         •         ■         •         •         .3.59 
Inorganic, •         .96.41 


Adult 

Woman. 

81  63 

8.88 

2.55 

.97 

5.97 

a  trace 

5.97 
94.03 


Enamel  consists  of  hexagonal  or  polygonal  fibres  or  rods  arranged 


TOOTH   STRUCTURES. 


139 


in  waved  lines  perpendicularly  to  the  dentine 
situated  on  the  most  promi- 
nent part  of  the  crown  are 
arranged  in  a  vertical  direc- 
tion ;  those  upon  the  side  are 
placed  horizontally,  whilst 
the  intermediate  fibres  pre- 
sent all  degrees  of  obliquity. 
As  these  fibres  necessarily 
diverge  from  the  dentinal  to 
their  free  surface,  the  upper 
space  thus  occasioned  must 
be  filled  by  the  gradual  en- 
largement of  the  fibres  from 
within  outward,  or  by  the 
addition  of  supplemental 
fibres. 

The  latter  assumption  Mr. 
Tomes  thinks  the  correct  one, 
although  difficult  of  demon- 
stration. The  enamel  rods 
are  marked  by  transverse 
striae,  which  indicate,  ac- 
cording to  Mr.  Beale,  the 
successive  .layers  of  calcifi- 
cation, and  are  much  more 
strongly  pronounced  in  some 
specimens  than  in  others, 
being  most  markedly  so  in 
the  enamel  of  unhealthy 
subjects. 

Upon  opening  a  dental  sac 
from  a  foetal  jaw,  interposed 
between  the  inner  surface  of 
the  sac  and  the  coronal  sur- 
face of  the  tooth,  a  semi- 
fluid, gelatinous  substance 
will  be  found,  composed  of 
nucleated  cylindrical  col- 
umns with  more  or  less 
spherical  nucleated  cells 
enveloped  in  fluid.  Similar 
columns   will  be   found    on 


Those  fibres  or  rods 


Fig. 


HLMAiN     LNAMhl,     I  ROM     IHC    JIASlltAltM,     SURFACE     OP   A 
MOLAK. 

The  figure  is  merely  intended  to  show  the  general  direc- 
tion of  the  fibres. 


CAVITIES    IN    HUMAN    EIsAMEL, 

Which  communicate  with  the  dentinal  tubes. 


140  PRIXCIPLES   AXD    PRACTICE    OF    DENTISTRY. 

the  inner  surface  of  the  sac.  This  is  the  enamel  organ,  or  enamel  pulp, 
and  from  it  the  cells  found  in  the  gelatinous  fluid  have  become  sepa- 
rated. Columns  of  a  like  kind  are  also  found  on  the  surface  of  the 
enamel.  "When  the  tooth  makes  its  way  through  the  gum,  and  before 
it  has  suffered  from  friction,  by  the  action  of  hydrochloric  or  acetic 
acid,  a  membrane-like  substance  may  be  raised  from  the  surface  of  the 
enamel,  which  is  seen  under  the  microscope  to  consist  on  one  side  of 
"columns  of  the  enamel  pulp,  and  on  the  other  of  decalcified  enamel 
fibres,"  joined  end  to  end,  but  easily  separated  at  their  point  of  junction. 

This  membrane,  to  which  Mr.  Xasmyth  first  drew  attention,  is  de- 
scribed as  the  persistent  dental  capsule ;  but  ]\Ir.  Huxley  thinks  it  is 
identical  with  tbe  membrana  prseformativa. 

The  enamel  differs  from  dentine  in  its  greater  density;  the  much 
earlier  period  at  which  entire  calcification  takes  place ;  the  absence, 
except  in  abnormal  conditions,  of  any  uncalcified  portions ;  the 
direction  in  which  calcification  progresses ;  and  in  the  fact  that  it  is 
the  least  constant  of  the  dental  tissues.  In  pathological  conditions 
irregular  cavities  are  sometimes  found  in  the  enamel  near  to  the 
surface  of  the  dentine,  and  in  such  cases  the  dentinal  tubes  may 
communicate  with  them  (Fig.  64.;  In  some  cases  the  dentinal  tubes 
may  enter  the  enamel,  but  this  condition  is  more  common  to  some 
animals  than  to  the  human  subject.  "  It  is  more  frequently  absent 
than  present  in  the  teetb  of  the  class  of  fishes ;  it  is  wanting  in  the 
entire  order  Ophidia  among  existing  reptiles ;  and  it  forms  no  part 
of  the  teeth  of  the  Edentata,  and  many  cetacea  among  mammals." 
(Owen's  "  Odontography,"  xxiv. ; 

Dextixe. — "With  regard  to  the  manner  of  the  formation  of  the 
dentine,  the  first  step  in  this  process  is  the  development  of  the 
odontoblasts,  which  have  the  same  relation  in  the  development  of  the 
teeth  as  osteoblasts  have  in  the  formation  of  bone.  The  odontoblasts 
are  large  nucleated  cells,  of  elongated  form,  provided  with  numerous 
processes  developed  from  the  dentinal  papilla,  which  at  that  early 
stage  consists  of  fine  fibrous  tissue  containing  many  cells.  The  odonto- 
blasts send  out  processes,  which,  as  they  develop,  become  calcified 
externally,  the  calcified  portion  forming  the  dentine,  and  the  uncalci- 
fied part  the  dentinal  fibrillse,  and  the  lateral  processes  the  branches  of 
anastomosis  through  which  the  tubuli  or  canals  of  the  dentine  com- 
municate. 

The  remains  of  the  odontoblasts  themselves  form  the  investment  of 
the  pulp,  situated  between  its  nerves  and  vessels  and  the  dentine,  a 
cellular  laver  known  as  the  viembrana  eborU,  or  ivory  membrane  of 
Kolliker.     (See  Origin  and  Formation  of  the  Teeth.) 

The  greater  portion,  or  body,  of  every  tooth  is  composed  of  dentine, 


TOOTH   STRUCTURES. 


141 


which  is  a  yellowish-white,  semi-transparent,  hard,  elastic  substance, 
and  intermediate  in  consistence  between  the  enamel  and  the  cementum. 
In  a  normal  condition  the  dentine  is  never  exjDosed,  being  covered  in 
the  crown  of  the  tooth  by  the  enamel,  and  in  the  root  by  the  cementum. 

In  a  fresh  specimen  the  human  tooth  is  found  to  consist  of  62  per 
cent,  of  its  weight  in  organic  salts,  28  per  cent,  of  tooth  cartilage 
(organic  matter),  and  10  per  cent,  of  water. 

Berzelius  gives  the  following  analysis  of  dentine : — 

Calcium  Phosphate, 62.00 

Calcium  Carbonate, 5.50 

Calcium  Fluoride, 2.00 

Magnesium  Phosphate,        .         .         .         .         .         .         .         .1.00 

Sodium  Salts, 1.50 

Gelatin  and  Water, 28.00 

Von  Bibra  gives — 

Calcium  Phosphate  and  Fluoride,   .         .         .         .         .         .         67.54 

Calcium  Carbonate, 7.97 

Magnesium  Phosphate,    ........  2.49 

Salts, 1.00 

Fat, 58 

Cartilage, 20.42 

While  the  organic  basis  of  the  matrix  of  dentine  is  similar  to  that  of 
bone,  yet  it  is  not  identical,  being  of  firmer  consistence,  and  does  not 
yield  gelatine  when  boiled.  A  fresh  section,  of  dentine  presents  a 
satiny  aspect,  but  when  submitted  to  the  microscope  it  is  found  to  con- 
sist of  a  multitude  of  fine  tubes,  known  as  the  dentinal  tubuU,  with 
an  intertubidar  substance.    These 

minute  tubes  permeate  the  entire  tig.  63.     ^____^^^ 

structure   of  the   dentine,  their  ("©     e     ~   O  \^        (^^sBliB^i 

direction  varying  in  the  different  /  ^  ®  ®  \  (®4^^®§^^1 
parts  of  the 'tooth.     Each  tube  \^&®^®      ®J     S^|M,I 

originates   by  an  open,  circular       P  @®®  f       7     ^^^i'^®/ 

mouth  or  orifice  upon  the  surface      j^  Q  °  ^'  ^  ^^^ 

of  the  pulp  cavity,  where  it  runs  trTxsvekse  section  or  dzktine. 

toward     the    periphery    of    the 

dentine  in  a  direction  usually  perpendicular  to  the  surface,  just  before 
reaching  which  it  divides  into  branches. 

Proceeding  in  a  wavy  and  radiated  manner  throughout  every  portion 
of  the  dentine  to  its  periphery,  these  tubes,  although  generally  termi- 
nating at  that  point,  in  some  instances  extend  beyond  and  encroach 
upon  the  enamel  or  upon  the  cementum.  When  the  latter  is  the  case, 
they  may  communicate  with  the  canaliculi  and  lacunse. 

Toward  the  grinding  surface  of  the  crown  of  a  tooth,  when  occlusion 


142 


PRINCIPLES   AND    PRACTICE    OF   DENTISTRY. 


is  received,  these  tubes  have  a  vertical  direction,  and  a  horizontal 
direction  when  the  pressure  of  adjoining  teeth  has  to  be  resisted  ;  and 
thus  the  shock  of  occlusion  and  pressure  is  more  generally  distributed 
over  the  entire  tooth  structure.  These  dentinal  tubes,  instead  of  pur- 
suing a  straight  course,  describe  curves,  the  longer  ones  less  abruptly- 
defined  than  the  others,  and  are  termed  "primary  curvatures,"  the 
latter  being  more  common  to  the  crown  than  to  the  root.  The 
secondary  curvatures,  although  smaller  than  the  primary,  are 
much  more  numerous.  The  coincidence  of  the  primary  curvatures 
of  adjoining  dentinal  tubes,  or  the  presence  of  rows  of  what  are 
known  as  "interglobular  spaces"  (Fig.  64;,  may  occasion  a  striated 
or  laminated  appearance  of  the  dentine,  the  lines  thus  formed  being 
at  nearly  right  angles  with  the  tubes  and  known  as  the  contour  lines 


rF.NTIXE  AM)  CEMENTUM  FEOM  THE  ROOT  OF  A  HUMAN  INTISOE;    COPIED  FROM  kOLLTKER. 

o.  Dentinal  fibres  or  tubes;  h.  interglobular  spaces,  having  the  appearance  of  the  Incunm  in  bone; 
c.  smaller  interglobular  spaces;  d.  commencement  of  the  cementum,  with  numerous  canals  close 
together;  e.  its  lamellx;  f.  lacunie;  g.  canals. 

of  Owen.     They  proceed  in  an  arched  manner,  somewhat  parallel  to 
each  other. 

The  dentinal  tubes  are  cemented  together  by  a  sub-granular  matter, 
radiating  from  the  cavity  to  the  surface  of  the  tooth.  From  these 
tubes  branches  are  given  ofi"  in  great  number  in  the  roots  and  as  the 
enamel  approaches  the  dentinal  surface.  In  the  crown  these  branches 
are  few  in  number.  They  anastomose  freely  with  each  other  and  with 
the  superficial  dental  tissues.  They  terminate  in  loops  or  are  lost  in 
the  enamel.  By  their  extension  into  the  superficial  dental  tissues  a 
close  union  is  formed  between  them  and  the  dentine,  notwithstanding 
the  fact  that  each  tissue  is  developed  from  a  distinct  formative  pulp. 
Kolliker  thought  these  tubes  contained  clear  fluid  in  the  fresh  state. 
In  the  dried  preparation  they  are  empty,  and  are  readily  permeated 


TOOTH   STRUCTURES. 


143 


Fig.  65. 


TERMINATION  OF  A  DENTINAL  TL"BE  IN  THE  MIDST  OF  THE 
DENTINE — HUMAN. 


by  colored  fluid.  These  facts 
gave  rise  to  the  opinion,  that 
their  sole  purpose  was  the  con- 
duct of  nutrient  fluids.  Mr. 
Tomes,  however,  following  Nas- 
myth,  objected  to  this  theory  on 
purely  physiological  grounds. 
The  extreme  sensitiveness  of  an 
exposed  coronal  surface  from 
which  a  portion  of  enamel  has 
been  broken  ;  the  fact  that  in 
operations  for  the  removal  of  carious  dentine  the  sensitiveness  was 
found  to  be  greatest  just  beneath  the  enamel ;  and  furthermore,  that 
when  the  pulp  was  broken  up  or  destroyed  by  escharotics,  this  sensi- 
bility was  lost,  led  him  to  conclude  that  the  sensibility  of  the  dentine 
depended  on  its  connection  Avith  the  pulp,  and  to  suppose  that  these 
tube  contents  might  be  in  some  way  associated  with  the  sensibility  of 
the  structure  in  which  they  were  found,  serving  to  establish  connection 
between  it  and  the  pulps,  to  which  supposition  fluid  contents  opposed 
an  insurmountable  difiiculty.  Led  by  this  train  of  reasoning  to  a 
careful  examination  of  the  tubes,  he  found  "each  dentinal  tube  ten- 
anted by  a  soft  fibril,  which,  after  passing  from  the  pulp  into  the  tube, 
follows  its  ramifications,  and  (TCmes'  Dental  Surgery,  327)  that  these 
fibrils  may  be  traced  into  the  dentinal  pulps."  Professor  KoUiker  and 
M.  Lent  had  previously  seen  processes  ex- 
tending from  the  "  peripheral  cells  of  the 
dentinal  pulp  ;"  but  had  supposed  them  "  or- 
ganisms for  the  development  of  the  dentinal 
tubes."  Mr.  Tomes  was  unable  to  determine 
the  manner  in  which  the  fibrils  terminated 
in  the  pulp,  whether  by  cells  or  by  any 
communication  with  nerves ;  but  does  not, 
therefore,  question  the  function  he  has  as- 
signed them,  since,  when  their  connection 
with  the  pulp  is  cut  off",  all  sensibility  is  lost 
to  the  dentine.  He  adds,  "  It  is  by  no  means 
necessary  to  assume  that  the  dentinal  fibrils  are  actually  nerves, 
before  allowing  them  the  power  of  communicating  sensation.  Many 
animals  are  endowed  with  sensation  which  yet  possess  no  demonstrable 
nervous  system  ;"  whilst,  at  the  same  time,  it  has  been  impossible  to 
demonstrate  nerves  in  the  human  body  so  numerous  as  to  w'arrant  the 
assumption  that  at  every  prick  of  a  needle  the  point  must  touch  a 
nerve  fibre.    Again,  the  greater  sensibility  of  the  dentine  immediately 


A  FRAGMENT  OF  DENTINE, 

a,  through  which  run  the  soft- 
er fibrils,  c,  which  seem  to  be  con- 
tinuous with  the  odontoblast  cells, 
6  (after  Dr.  Lionel  Beale). 


144 


PRINCIPLES   AND   PRACTICE   OF   DENTISTRY. 


Fig.  67. 


SECTION  OF  DRNTINE, 

From  the  edge  of  which  hang  out  the  dentinal 
sheaths,  and  bej'ond  these  again  the  fibrils  (after 
Boll). 


beneath  the  enamel  is  satisfactorily  accounted  for  by  the  law  which 
refers  to  all  nerves  the  greatest  sensibility  at  their  terminal  extremities. 

Mr.  Tomes  also  thinks  "  the  fore- 
going facts  will  warrant  the  con- 
clusion that  the  dentinal  fibrils 
are  subservient,  not  only  to  sensa- 
tion in  the  dentine,  but  that  they 
are  also  the  channels  by  which  the 
nutrition  of  this  tissue  is  carried 
on,"  and  argues  very  forcibly  that 
they  do  convey  nutrient  fluids, 
from  the  fact  that  the  tubes  are 
capable  of  undergoing  structural  change,  and  that  the  fibrils  may  also 
become  calcified  at  their  distal  extremities,  and  that  the  calcifying 
material  must  be  derived  from  the  pulp,  reaching  the  place  of  deposit 
through  the  fibrils.  Difiering  in  this  from  Dr.  Beale,  who,  Avhilst 
agreeing  with  Mr.  Tomes  as  to  the  presence  of  these  fibrils,  which  he 
has  himself  succeeded  in  demonstrating,  is  of  the  opinion  that  the 
so-called  dentinal  tubes  "  are  not  tubes,  nor  are  they  canals  for  the 
transition  of  nutrient  substances  dissolved  in  fluids."  He  considers 
these  fibrils  as  simple  germinal  matter  communicating  with  the  germi- 
nal matter  on  the  surface  of  the  pulp,  and  that  the  tubes  are  the 
formed  material  of  this  fibrillar  germinal  matter.  "  The  wall  of  the 
tubes  with  the  matter  between  the  tubes  corresponds  to  the  'wall'  of 
an  ordinary  cell,  or  to  this  and  the  intercellular  substance  (my  formed 
material),  and  the  central  part  of  the  contents  of  the  tube  to  granular 
cell  contents  with  the  nuclei  (my  germinal  matter).  If  you  look  at 
the  tissue  of  the  pulp  just  beneath  the  surface  of 
the  dentine  you  find  a  number  of  oval  masses  of 
germinal  matter  colored  intensely  red  by  carmine. 
These  are  nearly  equidistant,  and  separated  from 
each  other  by  a  certain  quantity  of  material  which 
is  very  faintly  colored,  and  in  cases  where  the 
solution  was  not  very  strong  it  remained  colorless. 
This  colorless  matrix  is  continuous  with  the  inter- 
tubular  or  dentinal  tissue,  while  the  intensely  red 
germinal  matter,  or  rather,  a  prolongation  from  it, 
extends  to  the  dentinal  tubes."  (Beale  on  the 
TRANSVERSE  SECTION  Structurc  Eud  Growth  of  Tlssucs,  155.)  Dr.  Beale 
THROUGH  THE  DENTAL      ^dmlts  that  thc  deutiual  tubes  do  convey  nutrient 

TCBULI  OF  THE   ROOT   OF  1        •  l 

A  HUMAN  TOOTH,  flulds,  but  coutcnds  that  they  were  not  designed 

Magnified  350  diame-      f^^  ^i^^^  purposc.     He  says,  "  As  in  the  formation 

ters,  showing  their  nu-  i  i       i  -i      i  1    j?^ 

merous  anastomoses.  of  bonc  already  dcscribed,  spaces  or  pores  are  lett. 


Fig. 


TOOTH   STRUCTUEES.  145 

through  which  nutrient  matter  passes  toward  the  germinal  matter. 
In  this  way  very  fine  channels  result,  which  may  be  seen  in  the  dry 
tooth  passing  from  one  dentinal  tube  to  the  other."  (Structure  and 
Growth  of  Tissue,  167.) 

The  dentinal  fibrillse  appear  to  be  formed  by  the  peripheral  portions 
of  the  processes  of  the  odontoblasts,  after  the  latter  become  long  and 
narrow,  attaining  considerable  length. 

The  formation  of  dentine  begins  about  the  fourth  month  of  foetal 
life,  at  the  summit  of  the  papilla.  The  superficial  portion  of  the  crown 
is  first  formed,  and  afterward  undergoes  no  alteration  in  size,  all  sub- 
sequent growth  taking  place  on  the  surface  adjacent  to  the  dentinal 
pulp.  The  growth  of  the  root  takes  place  from  above,  downward  into 
the  alveolus  destined  to  receive  it.  Placed  at  right  angles  to  the  outer 
surface  of  the  pulp,  between  it  and  the  dentine  already  formed,  or 
before  any  dentine  is  formed,  is  situated  a  layer  of  "  elongated  cylin- 
drical bodies  or  cells,  Avith  nuclei"  somewhat  resembling  nucleated, 
columnar  epithelium.  With  regard  to  the  exact  share  taken  by  the 
pulp  in  the  formation  of  dentine,  Kolliker  says  a  layer  of  cells  forming 
the  peripheral  portion  of  the  pulp  are  immediately  concerned  in  its 
formation.  He  says,  that  from  the  base  of  the  dental  sacs  the  dental 
pulp  proceeds,  rich  in  vessels,  and  finally  also  in  nerves,  with  a  non- 
vascular external  portion.  The  latter  is  bounded  by  a  delicate,  struc- 
tureless membrane,  the  membrana  prseformativa  (Raschkow),  which 
has  no  further  relation  to  the  formation  of  the  tooth.  Beneath  this 
lie  cells  of  0.016  to  0.024^'^  in  length,  and  0.002  to  0.0045  in  breadth, 
with  very  beautiful  vesicular  nuclei,  and  distinct  single  or  multiple 
nucleoli.  They  are  arranged  close  together  over  the  whole  surface  of 
the  pulp,  like  an  epithelium,  though  not  so  closely  defined  as  it  would 
be,  but  gradually  passing,  at  least  apparently,  by  smaller  cells  into  the 
parenchyma.  In  vascular  pulps  an  additional  boundary  line  may  be 
traced,  inasmuch  as  the  capillary  loops  in  which  the  vessels  terminate 
do  not  penetrate  between  the  cylindrical  cells,  but  end  close  to  one 
another  upon  their  inner  surfaces,  so  that,  considering  that  the  dentine 
is  produced  by  the  cells  in  question,  we  might  be  justified  in  terming 
them  the  dentinal  membrane  or  membrana  eboris.  The  internal  portion 
of  the  pulp,  he  thinks,  consists  of  a  granular  matrix,  subsequently 
becoming  more  fibrous,  and  that  when  ossification  of  the  dentine  begins 
numerous  vessels  are  developed,  and  a  little  later  numerous  nerves 
also  make  their  appearance.  According  to  this  observer,  it  is  "  only 
the  most  external  epithelium-like  layer  of  cells,"  and  not  the  entire 
pulp,  which  is  engaged  in  the  production  of  dentine,  and  these  main- 
tain a  constant  thickness  "by  the  elongation  of  the  original  cells, 
accompanied  by  a  continual  multiplication  of  their  nuclei."  He  does 
lO 


146  PRINCIPLES  AND   PRACTICE   OF   DENTISTRY. 

not  consider  that  the  "same  cell  suffices  for  the  whole  duration  of  the 
dentine,"  but  that  new  cells  may  from  time  to  time  be  formed ;  and 
denies  that  the  whole  pulp  is  progressively  changed  into  dentinal  cells, 
and  thinks  its  only  purpose  is  to  support  the  vessels  essential  to  the 
growth  of  the  dentinal  cells,  from  wiiich  alone  the  dentine  is  formed, 
by  the  gradual  reception  of  calcareous  salts.  (From  "Tomes'  Dental 
Surgery,"  388.) 

M.  Lent  refers  the  formation  of  the  dentinal  tubes  to  a  "  series  of 
delicate  processes  extending  from  the  dentinal  pulp,  to  which  Kolliker 
assents,  and  thinks  it  probable  that  a  single  cell  may  generate  an 
entire  tube.  He  also  recognizes  the  existence  of  an  intertubular  sub- 
stance, which  he  believes  to  be  "  excreted  by  the  cells  in  common,  with- 
out structural  relation  to  individual  cells  or  their  prolongation." 

The  theory  advanced  by  Mr.  Beale  is,  that  on  the  dentinal  surface  of 
a  tissue  lying  on  the  pulp  are  found  certain  "  cells  like  columnar  cells," 
Avhich  are  in  relation  with  the  nerves  and  blood  vessels  of  the  pulp  into 
which  they  send  prolongations,  and  that  from  these  cells  alone  is  de- 
veloped the  dentine,  agreeing  in  so  much  with  Kolliker  and  Lent,  but 
does  not  hold  with  them  that  the  "  canals  are  direct  processes  of  the 
whole  dentinal  cells,"  nor  that  the  intertubular  substance  is  a  direct 
secretion  from  the  cells.  His  views  are,  briefly,  that  these  cells  or 
"  elementary  parts  "  are  situated  on  the  surface  of  the  pulp ;  that  they 
consist,  as  cells  do  everywhere,  of  germinal  matter  and  formed  mate- 
rial, and  that  the  so-called  intertubular  substance  is  but  the  oldest  part 
of  the  formed  material,  in  which,  by  the  gradual  deposition  of  mineral 
matter,  the  dentine  is  formed ;  growth  taking  place  here,  as  elsewhere, 
from  within  outward,  from  nuclei  or  germinal  matter  to  cell  wall  or 
formed  material,  while  calcification  takes  j)lace  in  the  opf>osite  direc- 
tion, from  the  oldest  and  most  distant  formed  material  toward  the 
germinal  matter.  We  have  said  calcification  takes  place  gradually, 
probably  during  the  life  of  the  individual  or  until  the  pulp  cavity  is 
obliterated ;  hence  we  have  a  central  mass  of  germinal  matter,  the  so- 
called  dental  fibrils,  surrounded  by  calcified  formed  material,  giving 
rise  to  a  tubular  appearance,  the  dental  tubes  ;  and  since  the  calcifying 
process  takes  place  from  without  inward,  the  germinal  matter  is  made 
to  present  the  appearance  =of  an  attenuated  fibre  gradually  enlarging 
as  it  approaches  the  pulp.  Upon  this  fibrillar  mass  the  calcifying  pro- 
cess continually  encroaches,  until  the  so-called  tube  is  obliterated. 
Until  this  is  accomplished,  however,  the  germinal  matter  must  be 
nourished  and  mineral  matter  must  be  conveyed  to  its  most  distant 
part  for  deposition,  and  if  this  conduct  of  nutrient  fluid  constitutes  a 
claim  to  the  name,  they  may  still  be  called  tubes. 

Notwithstanding  Mr.  Tomes'  inability  to  trace   any  communication 


TOOTH    STRUCTURES. 


147 


Fig.  69. 


between  this  fibrillar  matter  and  the  nerves  of  the  pulp,  such  connec- 
tion must  be  supposed  to  exist — Prof.  Christopher  Johnston,  of  Balti- 
more, succeeded  in  tracing  nervous  communication  with  the  dentine — 
and  to  it  we  must  refer  the  sensibility  of  this  tissue. 

On  account  of  the  tubes  dividing  into  minute  branches,  as  they  ap- 
proach the  surface  of  the  dentine,  they  appear  to  end  in  very  fine 
pointed  extremities.  Some  of  these  tubes  anostomose  with  the  branches 
of  others,  forming  loops  near  the  periphery,  while  others  terminate 
deeper  in  the  tissue.  The  inner  walls  of  the  tubes  surrounding  the 
fibrill^e  constitute  the  dentinal  sheaths,  which  are  apparently  of  fibrous 
structure. 

The  intertuhidcvr  tissue  contains 
the  greater  part  of  the  earthy 
constituents  of  the  dentine,  and 
under  the  microscope  presents  a 
granular  appearance. 

What  are  known  as  inter- 
globular spaces,  are  indicators  of 
arrested  development  of  the  den- 
tinal tissue,  and  are  not  con- 
sidered to  be  normal.  These 
spaces  are  dark  and  irregular, 
and  are  most  commonly  observed 
a  little  distance  below  the  surface, 
in  a  discolored  and  imperfectly 
developed  tooth  ;  they  have  a 
ragged  outline.  According  to 
Bodecker,  soft  living  plasm  is 
found  in  the  smaller  interglo- 
bular spaces. 

According  to  Krause,  dentine 
has  a  specific  gravity  of  2.080, 
and  contains  less  earthy  matter 
than  the  enamel,  but  more  animal 
substance,  which  accounts  for  the 
rapid  progress  of  caries  when  the 
dentine  is  exposed. 

Cementum. — Cementum  is  de- 
veloped from  the  deeper  tissues 
of  the  foetal  jaw,  precisely  like 
bone  is  produced  in  other  parts 
of  the  body,  by  periosteal  ossifi- 

,•  Tj.  ^     •  ^•         T  THICK   LAMINATED   CEMENTIM, 

cation.       it      con  tarns     CanallCUll  From  the  root  of  a  human  tooth. 


^ 
^ 

% 


IXTEnGI.OBUr.AR  SPACES  IN  DENTINE. 


Fig 


148  PEINCIPLES  AND   PRACTICE   OF   DENTISTRY. 

and  lacunre,  and,  according  to  Salter,  Haversian  canals  in  the  thicker 
portion. 

It  is  not  so  dense  as  the  dentine,  and  approaches  more  nearly  in 
character  true  bone,  which  is  necessary  in  order  that  the  tooth  may  be 
tolerated  by  the  more  highly  vitalized  structures  in  relation  with  it. 

The  analysis  of  cementum  is  as  follows  : — 

Calcium  Phosphate  and  Fluoride, 58.73 

Calcium  Carbonate,    .         .         .         .         .         .         .         .         .7.22 

Magnesium  Phosphate,  ........  0.99 

Salts, 0.82 

Cartilage 31.31 

Fat, 0.93 

The  Cement,  or  Crusta  Petrosa,  is  the  most  highly  organized  of  the 
dental  structures.  It  covers  the  roots  of  all  the  teeth,  encroaching 
slightly  upon  the  crown,  where  it  overlaps  the  enamel.  Its  purpose  is 
to  bind  the  teeth  securely  in  the  alveoli,  forming  the  vital  bond  be- 
tween the  bone  and  the  commonly  unvascular  constituents  of  the  teeth. 
It  is  thickest  about  the  terminal  part  of  the  root,  gradually  thinning 
as  it  approaches  the  crown.  According  to  Mr.  Tomes,  "its  structural 
character  depends  upon  the  amount  of  tissue  present."  In  the  thicker 
parts  the  canaliculi  are  seen  anastomosing  freely  with  each  other,  and 
establishing  vascular  relations  between  the  several  lacunge ;  and  they 
"  occasionally  become  connected  with  the  terminal  branches  of  the 
dental  tubuli."  This  communication,  though  doubted  by  many  ob- 
servers, Mr.  Tomes  considers  demonstrated  "  beyond  cavil  "  by  prepara- 
tions in  his  possession.  Haversian  canals,  as  was  before  remarked,  are 
also  found  in  very  thick  sections  of  cementum  ;  but  M.  Morel  is  of 
opinion  that  these  canals  are  only  found  where  cementum  has  been 
morbidly  developed ;  but  Mr.  Tomes  is  of  a  different  opinion,  and  says 
tliat  where  two  roots  are  united  by  cementum  a  vascular  canal  will  not 
unfrequently  be  found  in  it,  and  that  this  appearance  "  is  not  neces- 
sarilv  an  evidence  of  disease."     The  lacunre 

Fir    71 

and  canaliculi  of  cementum  are  distributed 
lengthwise  around  the  root,  those  in  prox- 
imity to  the  dentine  joining  with  tlie  termi- 
nal branches  of  the  dentinal  tubuli,  while 
those  upon  the  external  surface  radiate 
toward  the  investing  membrane. 
1),    ,,,.,,..  ,      uam  ^y  sixoh.  a  provision,  even  after  the  de- 

iiiili&iiliilM       vitaiization    and  removal  of  the   pulp,  the 
LAorsA  OF  CEMENTUM,  yitalltv  uot  ouW  of  the  cementum  but  of  the 

W  hich  communicates  with  the  ter-  *'  .  .         .        , 

Bni.atiou  of  the  dental  tubes.  dentine  of  the  teeth  is  maintained. 


TOOTH   STRUCTURES. 


149 


Fiu 


From  irritation  of  the  dental  periosteum  the  cementum  often  becomes 
hypertrophied,  the  affection  being  known  as  "  dental  exostosis." 
Cementum  contains  more  animal  matter  than  the  dentine,  and  becomes 
very  sensitive  when  exposed  by  the  recession  of  the  gum  about  the 
neck  of  the  tooth. 

OsTEO-DENTiJf  E. — Ostco  or  Secondary  dentine  is  a  substance  partaking 
more  of  the  nature  of  cementum  than  of  ordinary  dentine,  as  it  pos- 
sesses no  true  dentinal  tubes,  but  canals  similar  to  the  canaliculi  of 
bone.  It  is  generally  formed  in  the  teeth  of  persons  of  advanced  age, 
where  the  pulp  cavity  is  very  much  diminished  in  size,  and  it  also 
forms  a  protection  against  the  exposure  of  the  pulp  of  a  tooth  which 
has  been  denuded  of  its  natural  tissues  by  mechanical  abrasion,  the 
action  of  caries,  or  by  fracture.  In  other  cases  secondary  dentine  is 
deposited  in  isolated  nodules  scattered  throughout  the  substance  of  the 
dental  pulp,  which  may  unite  and  form  larger  masses  and  become 
adherent  to  the  walls  of  the  pulp  cavity.  Some  of  these  masses  are 
occasionally  penetrated  by  blood  vessels,  and  surrounded  by  concentric 
lamellse,  like  the  Haversian  canals  of  bone. 

The  dividing  line  between 
the  primitive  and  secondary 
formations  of  dentine  is  char- 
acterized by  numerous  irregu- 
lar spaces  and  globular  con- 
tours, while  deeper  in  the 
mass  of  lately  formed  second- 
ary dentine  tubes  or  canals 
may  exist. 

Not  infrequently,  however, 
the  tubuli  of  secondary  den- 
tine are  arranged  in  a  very 
irregular  manner,  either  "  in 
tufts  or  in  bundles,  and  with- 
out any  apparent  reference  to 
points  of  radiation."  Osteo- 
dentine  is  also  usually  very 
transparent,  on  account  of  this 
tissue  being  devoid  of  light- 
refracting  tubes,  its  canals 
being  so  completely  filled  up 
with  the  secondary  deposit 
that  they  permit  the  transmission  of  light.  The  tubuli  of  normal 
dentine  are  frequently  filled  with  a  secondary  deposit,  especially  in  the 


SECONDARY   DENTINE, 

FilliDg  up  one  of  the  cornua  of  the  pulp  cavity. 
a,  human  molar  affected  by  caries. 


150  PRINCIPLES  AND   PRACTICE   OF   DENTISTRY. 

roots  of  teeth,  and  to  which  the  name  "  horny  dentine  "  has  been  given. 
The  formation  of  secondary  dentine  appears  to  depend  upon  irritation 
of  the  pulp,  of  long  continuance  but  restricted  as  to  degree,  and  during 
the  time  "  that  the  slow  conversion  of  the  organ  is  taking  place  the 
dentinal  fibrillte  also  become  impregnated  with  calcareous  matter  and 
solidify." 


PART  SECOND. 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


CHAPTER  I. 

GENERAL   CONSIDERATIONS. 

THE  susceptibility  of  the  human  body  to  morbid  impressions  differs 
in  different  individuals.  In  some,  its  functional  operations  are 
liable  to  derangement,  from  the  most  trifling  causes ;  in  others  they 
are  less  easily  disturbed.  Nor  do  the  same  causes  always  produce  the 
same  results.  Their  effects  are  determined  by  the  tendency  of  the 
organism  and  the  susceptibility  of  the  part  on  which  they  act ;  both 
with  regard  to  constitutional  and  local  disease,  this  is  true  of  the 
organism  generally,  and  of  all  its  parts  separately  considered,  but  of 
none  more  than  the  teeth,  gums  and  alveolar  processes.  The  teeth  of 
some  persons  are  so  susceptible  to  the  action  of  corrosive  agents,  as  to 
become  involved  in  general  and  rapid  decay,  as  soon  as  they  emerge 
from  the  gums ;  while  those  of  others,  though  exposed  to  the  same 
causes,  remain  unaffected  through  life.  A  similar  difference  of  sus- 
ceptibility also  exists  in  the  parts  within  which  these  organs  are  con- 
tained. 

With  the  teeth  these  differences  of  susceptibility  to  morbid  impi'es- 
sions  are  implanted  in  them  at  the  time  of  their  formation,  and  are 
the  result  of  the  different  degrees  of  perfection  in  which  this  process 
is  accomplished.  In  proportion  as  these  organs  are  perfect,  is  their 
capability  of  resisting  the  action  of  destructive  agents  increased,  and 
as  they  are  otherwise,  it  is  diminished.  This  is  true  of  every  part  of 
the  body ;  but  as  the  teeth  are  formed,  so  they  continue  through  life, 
if  not  impaired  by  disease,  except  that  they  gradually  acquire  a  very 
slight  increase  of  density,  whereby  their  liability  to  caries  is  corres- 
pondingly lessened. 

Not  so,  however,  with  the  other  parts  of  the  body.  They  may  be 
innately  delicate  or  imperfectly  developed,  and  afterward  become  firm 
and  strong,  or  be  at  first  healthy  and  well  formed,  and  subsequently 
become  impaired ;  and  in  proportion  as  they  undergo  these  changes, 
is  their  susceptibility  to  disease  increased  or  diminished.  But  the 
teeth  are  not  governed  by  the  same  laws,  either  physical  or  vital, 
that  regulate  the  operations  of  the  other  parts  of  the  animal  economy. 
Not  only  the  manner  of  their  formation,  but  their  diseases,  also,  are 
different.  The  other  tissues  of  the  body,  not  excepting  the  osseous,  are 
endowed  with  recuperative  powers,  whereby  an  injury  is  repaired  by 

153 


154  DENTAL  PATHOLOGY,  THERAPEUTICS. 

their  own  inherent  energies ;  but  the  teeth  do  not  possess  such  attri- 
butes. 

Assuming  these  propositions  to  be  true — and  that  they  are,  especially 
those  with  regard  to  the  teeth,  we  shall  endeavor  to  show — it  becomes 
an  object  of  considerable  importance  to  discover  the  signs  by  which 
the  susceptibility  of  the  human  organism  to  disease  may  be  determined. 
But  to  do  this,  except  in  so  far  as  the  teeth,  gums  and  alveolar  pro- 
cesses are  concerned,  is  not  our  present  object ;  yet,  in  the  prosecution 
of  the  task  we  have  undertaken,  we  shall  have  occasion  to  advert  to 
certain  constitutional  and  local  tendencies  indicated  by  the  appear- 
ance and  condition  of  the  teeth  and  other  parts  of  the  mouth. 

M.  Delabarre  affirms  that,  by  an  inspection  of  the  teeth,  we  can 
ascertain  whether  the  innate  constitution  is  good  or  bad,  and  our  own 
observations  go  to  confirm  the  truth  of  this  opinion  ;  but,  as  this  author 
adds,  these  are  not  the  only  organs  that  should  be  interrogated.  The 
lips,  the  gums,  the  tongue,  and  the  fluids  of  the  mouth,  should  also  be 
examined,  to  discover  the  health  of  the  organism,  and  ascertain  whether 
the  original  condition  of  the  constitution  has  undergone  any  change. 

Those  who  have  not  been  in  the  constant  habit  of  closely  observing 
the  appearances  met  with  in  the  mouth,  may  be  skeptical  with  regard 
to  the  information  that  may  thus  be  derived  ;  but  those  who  have 
studied  them  with  care  will  not  hesitate  to  say  that  they  are,  in  many 
instances,  more  certain  and  accurate  than  any  which  can  be  obtained 
from  other  physical  appearances.  For  example :  the  periods  of  the 
dentinification  of  the  different  classes  of  both  sets  of  teeth  being  known, 
we  are  enabled  to  infer  whether  the  innate  constitution  be  good  or  bad, 
from  the  physical  condition  of  these  organs ;  for,  as  the  functions  of 
the  organism  are  at  this  time  healthily  or  unhealthily  performed,  will 
they  be  perfect  or  imperfect,  or,  in  other  words,  will  their  texture  be 
hard  or  soft  ? 

It  is  well  known  to  writers  on  odontology,  that  the  teeth  of  the 
child,  like  other  parts  of  the  body,  usually  resemble  those  of  its 
parents ;  so  that  when  those  of  the  father  or  mother  are  bad  or  irregu- 
larly arranged,  a  similar  imperfection  is  generally  found  to  exist  in 
those  of  the  offspring ;  but  this  does  not  necessarily  follow,  and  when 
it  does,  it  is  the  result  of  the  transmission  of  some  constitutional 
impairment,  whereby  the  formative  operation  of  these  organs  is  either 
disturbed  or  prevented  from  being  effected  in  a  perfect  and  healthy 
manner.  The  quality  of  the  teeth  of  the  child,  therefore,  may  be  said 
to  depend  on  the  health  of  the  mother,  and  the  aliment  from  which  it 
derives  its  subsistence.  If  the  mother  be  healthy,  and  the  nourish- 
ment of  the  child  of  good  quality,  the  teeth  will  be  dense  and  compact 
in  their  texture,  generally  well  formed  and  well  arranged,  and  as  a 


GENERAL   CONSIDERATIOXS.  155 

consequence  less  liable  to  be  acted  on  by  morbid  secretions  than  those 
of  children  deriving  their  being  from  unhealthy  mothers,  and  subsist- 
ing upon  aliment  of  a  bad  quality.  Temperament,  also,  exercises  au 
influence  upon  the  functional  operations  of  the  body. 

The  Temperament  in  Relation  to  the  Teeth. — Before  proceeding 
further,  it  may  be  well  to  notice  the  individual  conditions  or  qualities 
known  as  temperaments.  The  word  temperament  is  derived  from  tlie 
Latin  tempera,  "  to  mix  together,"  and  implies  the  constitution  as 
determined  by  the  predominance  of  certain  constituents  of  the  body. 
For  among  the  ancients  it  was  supposed  that  the  manifestations  of  the 
functions  were  tempered  or  so  determined  by  the  predominance  of  any 
one  of  the  three  humors  then  recognized,  namely  :  blood,  lymph,  bile, 
and  atrabilis,  or  black  bile.  Dunglison,  in  his  Medical  Dictionary, 
defines  the  temperaments  to  be  those  individual  differences  which  con- 
sist in  "such  disproportion  of  parts,  as  regards  volume  and  activity, 
as  to  sensibly  modify  the  whole  organism,  but  without  interfering  with 
the  health ;"  in  other  words,  a  physiological  condition  in  which  the 
functions  of  the  different  organs  are  so  regulated  as  to  impress  certain 
characteristics  upon  each  individual.  Others  contend  that  these  indi- 
vidual difierences,  "though  they  can  scarcely  be  called  morbid,  yet 
certainly  give  a  proclivity  to  disease  in  the  direction  indicated  by  the 
temperaments." 

Dr.  James  W.  "White,  on  this  subject,  remarks  :  "  Temperament  may 
be  defined  as  a  constitutional  organization,  depending  primarily  upon 
heredity — national  or  ancestral — and  consisting  chiefly  in  a  certain 
relative  proportion  of  the  mechanical,  nutritive,  and  nervous  systems, 
and  the  relative  energy  of  the  various  functions  of  the  body — the 
reciprocal  action  of  the  digestive,  respiratory,  circulatory,  and  nerv- 
ous systems.  The  stomach,  liver,  lungs,  heart,  and  brain — digestion, 
assimilation,  respiration,  circulation,  and  innervation — are  all  factors 
in  the  difierentiation  of  temperament ;  and  according  to  the  congenital 
predominance  of  one  or  the  other,  and  the  relative  activity  of  these 
functions,  is  the  modification  of  the  characteristics  of  the  individual 
which  determines  his  position  as  to  temperament.  Each  temperament 
is  the  result  as  well  as  the  indication  of  the  preponderance  of  one  or 
another  of  these  systems,  and  of  relative  functional  activity. 

"  A  perfect  equilibrium  of  the  different  systems  is  rarely  if  ever 
presented  in  any  individual.  One  having  a  balance  of  all  the  tem- 
peraments would  be  temperamentless,  or  of  no  special  temperament. 
It  is  difficult,  in  some  cases,  to  decide  positively  to  which  variety  a 
special  case  belongs,  the  several  temperaments  being  combined  and 
blended  in  such  ever-varying  proportions.  Not  infrequently  the  in- 
dications are  even  contradictory,  and  the  blending  of  several  tern- 


156  DENTAL  PATHOLOGY,  THERAPEUTICS. 

peraments  requires  a  nice  discrimination  to  define  the  admixture. 
The  primary  elements  of  temperament  are  susceptible  of  such  mani- 
fold combinations ;  the  determining  forces  are  so  complex,  and  our 
knowledge  of  their  comparative  values  is  so  limited,  that  no  rule 
can  be  given  which  will  not  fail  in  numerous  instances  to  apply  in 
all  respects  to  individual  cases ;  but  that  there  is  a  general  relation 
between  constitutional  qualities  and  external  signs  does  not  admit 
of  question. 

"  Temperaments  are  readily  divisible  into  four  basal  classes — bilious, 
sanguineous,  nervous,  and  lymphatic ;  then  again  into  sub-classes  of 
mixed  temperaments — a  combination  of  two  or  more  of  the  primary 
divisions.  In  these  combinations  one  or  other  of  the  so-called  basal 
temperaments  predominates,  and  a  compound  term  is  used  to  express 
the  complexity,  as,  for  instance,  the  nervo-bilious,  signifying  that  the 
bilious  base — the  foundation  temperament — is  qualified  by  an  ad- 
mixture of  the  nervous  element,  and  so  throughout  the  series.  Twelve 
varieties  of  temperament,  in  addition  to  the  four  basal,  may  thus  be 
designated  by  the  combination  in  pairs  of  the  original  four.  The 
admixture  of  the  peculiarities  of  three  or  of  all  four  of  the  basal 
temperaments  results  in  what  are  denominated  respectively  ternary 
and  quaternary  combinations,  which  call  for  nice  discrimination  in 
diagnosis ;  but  even  such  complexities  are  registered  in  the  size,  form 
and  color  of  the  dental  organs." 

The  sanguineous  temperament  is  characterized  by  a  fair,  ruddy 
complexion,  yellow,  red  or  light  auburn,  or  light-brown  hair,  a  good 
class  of  teeth,  a  full  muscular  development,  large,  full  veins  and  active 
pulse,  indicating  an  abundant  supply  of  blood,  and  warm  extremities, 
all  showing  perfect  health,  and  in  females  a  tendency  to  voluptuous- 
ness. The  mind  is  hopeful  and  elastic,  yet  at  the  same  time  fickle  and 
volatile,  with  little  determination  and  perseverance.  Although  indi- 
cating perfect  health,  yet  in  this  temperament  diseases  are  prone  to 
assume  the  acute  form,  and  speedily  run  their  course  either  to  recovery 
or  a  fatal  termination. 

The  bilious  temperament  is  characterized  by  a  preponderance  of 
bile,  indicated  by  a  dark  or  sallow  countenance,  black  hair,  generally 
luxuriant,  a  slow  or  moderate  circulation  of  the  blood,  shown  by  a 
hard,  strong  pulse,  dark  eyes,  strong  teeth,  with  a  yellow  tinge  over  the 
entire  crown  ]  and  the  body,  instead  of  the  roundness  of  form  peculiar 
to  the  sanguine  temperament,  is  angular ;  wanting  in  ease  and  grace 
of  manner ;  there  is  restlessness,  but  at  the  same  time  great  force  of 
character  and  quickness  of  perception  and  power  of  will.  The  digest- 
ive oi'gans,  however,  are  more  liable  to  derangement  than  in  other 
temperaments,  indicating  some  defective  action  in  these  organs ;  the 


GENERAL    CONSIDERATIONS.  157 

liver,  of  course,  being  the  principal  one  affected,  and  necessitating  the 
use  of  mercury  as  a  stimulus. 

The  lymphatic  temjoerament  is  characterized  by  a  predominance  of 
lymph  or  phlegm  in  the  system  ;  and  persons  possessing  it  have  a 
general  softness  or  laxity  of  the  tissues,  the  proportion  of  the  fluids 
being  too  great  for  that  of  the  solids,  the  lymphatics  and  absorbents 
not  acting  so  thoroughly  as  to  prevent  the  cellular  tissue  from  being 
filled  with  humors;  so  that  there  is  a  want  of  sensibility.  The  com- 
plexion is  fair,  but  not  ruddy,  and  the  hair,  either  light  or  dark,  is 
not  luxuriant,  but  thin  and  straight.  The  eyes  are  light,  generally 
blue,  the  circulation  feeble,  and  the  pulse,  as  a  consequence,  weak,  and 
a  want  of  tone  in  the  system.  The  skin  is  pale,  flabby,  and  moist, 
and  the  body  is  heavy  and  rounded,  while  the  teeth,  although  they 
may  often  appear  comparatively  good,  yet  are  sensitive  and  not 
highly  organized.  Although  the  expression  denotes  a  want  of 
activity,  yet  there  is  a  clear  and  active  mind,  characterized  by 
prudence  and  sound  judgment  without  enthusiasm.  Owing  to  the 
predominance  of  lymph,  there  is  a  tendency  to  dropsy  and  chronic 
disease. 

The  nervous  temperament  is  characterized  by  the  predominance  of 
the  nervous  element,  and  by  great  activity  or  susceptibility  of  the 
great  nervous  centime — the  brain.  Persons  possessing  this  temperament 
are  distinguished  by  their  impressibility,  susceptibility  to  intense  feel- 
ing or  intense  excitement.  There  is  great  irritability,  anxiety,  and 
agitation,  which  peculiarities  enable  us  readily  to  recognize  it  by  the 
tone  of  voice  and  manner  of  speaking.  The  body  is  slender,  though 
well  formed,  the  complexion  pale  and  soft,  and  the  muscles  small  and 
yielding.  In  illness,  symptoms  are  often  complicated  with  those  of 
nervous  disorder,  and  the  mind  desponding.  There  is  want  of  power 
and  endurance. 

Upon  the  temperament  the  constitutional  health  depends  to  a  greater 
extent  than  pathologists  generally  admit ;  and  hence  it  is  that  that 
of  the  child  usually  partakes  of  that  of  one  or  other,  or  both,  of  its 
parents.  "  This,"  says  M.  Delabarre,  "  is  particularly  observable  in 
subjects  that  have  been  suckled  by  a  mother  or  nurse,  Avhose  tem- 
perament was  similar  to  theirs."  To  obviate  the  entailment  of  this 
evil,  he  recommends  mothers  having  teeth  constitutionally  bad  to  ab- 
stain from  suckling,  and  that  this  highly  important  office  be  intrusted 
to  a  nurse  having  good  teeth ;  asserting  at  the  same  time,  that  by  this 
means  the  transmission  of  so  troublesome  a  heritage  as  bad  teeth  may 
be  avoided. 

Dr.  J.  Foster  Flagg  gives  the  following  tabular  presentations  of  the 
relation  of  the  temperament  to  the  teeth  : — 


158 


DENTAL    PATHOLOGY,  THERAPEUTICS. 


H 

H 

ft 

H 

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c  rr. 


GENERAL   CONSIDERATIONS.  159 

Depending,  then,  as  the  physical  condition  of  the  teeth  and  the  or- 
ganism generally  confessedly  do,  upon  the  quality  of  the  nourishment 
from  which  subsistence  is  derived  during  infoncy  and  childhood,  it  is 
highly  essential  that  this  be  good  ;  and  that  that,  especially,  derived 
from  the  breast,  be  from  those  only  who  are  in  the  enjoyment  of  per- 
fect health  and  possess  good  constitutions. 

The  teeth,  while  in  a  pulpy  state,  partake  of  the  health  of  the 
organism  generally.  As  that  is  healthy  and  strong,  or  unhealthy  and 
weak,  so  will  the  elementary  principles  of  which  they  are  then  com- 
posed be  of  a  good  quality,  or  deteriorated ;  but  after  dentinification 
has  commenced,  the  solid  j)arts  cease  to  be  influenced  by,  or  to  obey 
the  laws  of,  the  other  parts  of  the  body.  If  the  general  health  be 
good  at  the  time  this  process  is  going  on,  it  will  be  evidenced  by  their 
density  and  color ;  if  bad,  in  the  looseness  of  their  texture,  etc. 

This  is  a  subject  to  which  we  have  paid  some  attention,  having  for 
a  long  time  been  in  the  habit  of  carefully  noting  the  differences  in  the 
appearance  of  the  teeth  of  different  individuals,  and  of  both  denti- 
tions;  and,  though  we  have  been  able  to  conjecture  in  some  instances, 
what  had  been  the  state  of  the  mother's  health  during  the  first  months 
of  pregnancy,  candor  compels  us  to  confess  that  we  have  never  been 
able  to  find  any  signs  in  tfie  peculiarity  of  their  shape,  size,  density,  or 
arrangement  that  indicated  it.  But  from  the  moment  that  the  part 
of  the  formative  process  of  these  organs  which  is  not  influenced  by 
subsequenf  changes  in  the  general  economy  commences,  certain  ]Decu- 
liarities  of  appearance  are  impressed  upon  them  that  continue  through 
life,  and  about  the  certainty  of  the  indications  of  which,  in  regard  to 
the  general  health,  we  think  there  can  be  no  doubt. 

With  regard  to  the  information  concerning  the  innate  constitution, 
to  be  derived  from  an  inspection  of  the  teeth,  it  has  been  well  re- 
marked by  Delabarre,  that  physicians  may  derive  much  advantage  in 
pointing  out  the  rules  of  domestic  hygiene  for  the  physical  education 
of  children  ;  for,  says  this  eminent  dentist,  "  Can  he  admit  of  but  one 
mode?  Has  he  not,  then,  the  greatest  interest  in  being  well  assured 
of  the  innate  constitution  of  each  child  for  whom  advice  is  required, 
to  enable  him  to  recommend  nutriment  suited  to  the  strength  of  its 
organs  ?  Will  he  report  only  on  a  superficial  examination  of  the  face, 
its  paleness,  the  color  of  the  skin,  all  of  which  are  variable  ?  Will 
he  not  regard  the  repletion  or  leanness  of  the  subject,  the  state  of  the 
pulse,  etc.  ?  Surely  he  will  make  good  inductions  from  all  these 
things  ;  but  the  minute  examination  of  the  mouth  will  give  him  be- 
yond doubt  the  means  of  confirming  his  judgment  ;  for,  besides  what 
we  already  know  of  the  teeth,  the  mucous  membrane  of  the  buccal 
cavity  receives  its  color  from  the  blood,  and  varies  according  to  the 


160  DENTAL    PATHOLOGY,  THERAPEUTICS. 

state  of  that  fluid."  This  is  a  matter  which  the  observation  9£  the 
dentist  has  an  opportunity  of  confirming  almost  every  day ;  and 
which,  when  taken  in  connection  with  the  physical  characteristics  of 
the  teeth,  together  with  those  of  the  salivary  and  mucous  secretions  of 
the  mouth,  constitute  data  from  which  both  the  innate  and  present 
state  of  the  constitutional  health  may  be  determined  with  accuracy 
and  certainty. 

The  symptoms  of  actual  disease  have  been  minutely  and  repeatedly 
described,  but  the  physiognomical  signs  by  which  the  susceptibility  of 
the  human  organism  to  morbid  impressions  is  determined,  and  the 
kind  of  malady  most  likely  to  result  therefrom,  do  not  aj^pear  to  be 
so  well  understood.  "  Whatever,"  says  the  author  last  quoted,  "  may 
be  the  knowledge  which  a  practitioner  may  acquire  of  the  changes 
which  a  disease,  or  even  any  tendency  to  disease,  may  effect  in  the 
functions  of  some  organs,  it  is,  at  least,  advantageous  to  be  able  to 
conjecture  what  has  happened  in  the  whole  of  the  system  at  some 
other  time.  In  fact,  can  a  physician,  when  about  to  prescribe  for  a 
flight  indisposition  of  a  person  whom  he  hardly  knows,  rely  entirely 
upon  the  symptomatology  of  the  tongue  ?  Does  not  its  aspect  singu- 
larly vary  ?  Is  it  not  notorious  that  in  certain  persons  it  is  always 
red,  white,  yellow,  or  blackish  ?  I  as  well  as  others  have  had  occa- 
sion to  make  these  observations  on  persons  with  whom  it  was  always 
thus,  yet  without  their  being  subject  to  any  of  those  indispositions  that 
are  so  common  in  the  course  of  life."  These  signs  are  as  variable  in 
sickness  as  in  health,  and,  consequently,  can  only  be  relied  upon  as 
confirmatory  of  the  correctness  of  oth^r  indications  which  manifest 
themselves  in  other  parts  of  the  body. 

The  physical  changes  produced  by,  and  characteristic  of,  disease 
have  been  described,  both  by  ancient  and  modern  medical  writers ;  but 
the  works  which  have  appeared  upon  this  subject  do  not  comprise  all 
that  is  necessary  to  be  known.  For  example,  if  we  examine  the  lips, 
tongue  and  gums  of  a  dozen  or  more  individuals  who  are  regarded  as 
in  health,  differences  in  their  appearance  and  condition  will  be  found 
to  exist.  The  lips  of  some  will  be  red,  soft,  and  thin ;  others,  red, 
thick,  and  of  a  firm  texture ;  some  will  be  thin  and  pale ;  others,  red 
on  the  inside  and  pale  on  the  edges  ;  some  are  constantly  bathed  with 
the  fluids  of  the  mouth  ;  others  are  dry  ;  and  these  differences  of  ap- 
pearance and  condition  are  as  marked  on  the  tongue  and  gums  as  they 
are  upon  the  lips,  and  are  supposed  to  be  attributable  to  the  pre- 
ponderance or  want  of  existence  in  sufficient  quantity  of  some  one  or 
more  of  the  elementary  principles  of  the  organism.  Hence  may  be 
said  to  result  the  difl!erences  in  temperament  and  susceptibility  of  the 
body  to  the  action  of  morbid  excitants. 


GENERAL   CONSIDERATIONS.  161 

If  the  quality  and  resi^ective  proportions  of  the  materials  furnished 
for  the  growth,  reparation  and  maintenance  of  the  several  organs  of 
the  body  be  good,  and  in  proper  proportion,  all  the  organs  will  be 
well  formed  and  endowed  with  health,  and,  as  a  consequence,  capable 
of  performing  their  respective  functions  in  a  healthy  manner.  But  if 
their  elementary  ingredients,  to  use  an  expression  of  the  author  from 
whom  we  have  just  quoted,  be  bad,  their  functions  will  be  more  or  less 
feebly  pei'formed. 

These  materials  are  furnished  by  the  blood.  From  this  fluid  each 
organ  receives  such  as  are  necessary  to  its  own  particular  organization. 
The  blood,  therefore,  exercises  an  important  influence  upon  the  whole 
system,  determining  the  health  of  all  its  parts,  which,  as  Delabarre 
says,  "is  relative  to  the  quantity  of  the  blood,  and  the  general  health 
results  from  that  of  all  parts  of  the  system."  In  order  to  do  this,  har- 
mony must  exist  between  all  the  organs ;  but  in  consequence  of  the 
great  variety  and  intermingling  of  temperaments,  it  rarely  does, 
except  perhaj)s  in  those  in  whom  the  sanguine  predominates,  and  who 
have  not  become  enervated  by  irregular  and  luxurious  living.  Even 
when  it  does  exist,  w^e  are  by  no  means  certain  that  it  will  continue  to' 
do  so ;  for,  exposed,  as  the  body  is,  to  a  thousand  causes  of  disease,  its 
functional  operations  may,  at  almost  any  moment,  become  disturbed. 
Among  the  civilized  nations  of  the  earth,  the  peasantry  of  Great 
Britain  probably  possess  as  good  constitutional  temperaments  as  are 
anywhere  to  be  found ;  and  yet,  with  these  people,  we  are  told,  that 
although  the  sanguineous  predominates  in  a  majority  of  cases,  it  is 
combined  and  intermingled,  in  a  greater  or  less  degree,  with  others. 

In  all  these  modifications  the  blood  plays   an  important  part:  it 
determines  the  temperament  of  the  individual,  and,  by  consequence, 
the  physical  condition  of  all  the  tissues  of  the  body  subject  to  the  gen- 
eral laws  of  the  economy.     But  the  dependence  between  the  solids  and 
this  fluid  is  mutual ;  it,  also,  is  dependent  upon  them,  and  the  condi- 
tion of  one  is  relative  to  that  of  the  other.     The  solids,  if  we  may  be 
permitted^the  use  of  the  metaphor,  are  the  distillery  of  the  fluids,  while 
they,  in  turn,  nourish,  repair,  and  maintain  the  solids.     A   change, 
then,  in  the  condition  of  one  is  followed  by  a  corresponding  change  in 
the  condition  of  the  other.     If  the  blood  be  of  an  impure  quality,  or 
any  of  the  ingredients  entering  into  its  composition  exist  in  too  great 
or  too  small  a  quantity,  it  will  fail  to  supply  the  solids  with  the  ma- 
terials necessary  to  the  healthful  performance  of  their  functions,  and, 
if  not  actual  disease,  a  tendency  to  it,  will  be  the  result.     And,  again, 
the  purity  of  the  blood  is  dependent  upon  the  manner  in  which  the 
solids  perform  their  offices.     While,  therefore,  duly  appreciating  the 
importance  of  this  fluid,  and  its  existence  in  a  pure  state,  to  the  gen- 
II 


162  DENTAL    PATHOLOGY,  THERAPEUTICS. 

eral  health  of  the  economy,  we  cannot  ascribe  to  it,  regardless  of  the 
functions  of  the  solids,  a  controlling  influence  over  the  organism. 

To  distinguish  all  the  nice  and  varied  shadings  of  temperament,  or 
states  of  the  constitutional  health,  by  the  physiognomical  appearances 
of  the  body,  is  perhaps  impossible,  or  can  only  be  done  with  great 
difficulty,  and  by  those  who  have  been  long  exercised  in  their  observ- 
ance ;  but  to  discover  that  which  predominates  is  not  so  difficult  a 
matter,  and  the  indications  are  nowhere  more  palpably  manifested 
than  in  the  mouth.  By  an  inspection  of  the  several  parts  of  this  cavity, 
together  with  the  fluids  and  the  earthy  matter  found  upon  the  teeth, 
we  believe  inductions  may  be  made,  not  only  with  regard  to  the 
innate  constitution,  but  also  with  regard  to  the  present  state  of  health, 
serviceable  both  to  the  dental  and  medical  practitioner ;  and,  in  the 
further  prosecution  of  this  inquiry,  we  shall  endeavor  to  point  out 
some  of  the  principal  of  the  indications  here  met  with,  to  state  the 
appearances  by  which  they  arc  distinguished,  and  to  offer  such  other 
general  reflections  as  the  subject  may,  from  time  to  time,  seem  to 
suggest. 


CHAPTER  II. 

DENTITION. 


THE  term  "  dentition  "  implies  the  eruption  of  the  teeth,  and  is  a 
process  which  consists  of  two  stages,  namely,  first  dentition  and 
second  dentition.  At  about  the  seventh  week  of  intra-uterine  existence 
the  process  of  development  of  the  teeth  of  first  dentition  begins,  and 
shortly  after  birth  the  outlines  of  the  forms  of  the  deciduous  teeth  may 
be  observed  on  the  external  aspect  of  the  jaws ;  but  as  age  advances, 
owing  to  the  increased  development  of  the  mucous  membrane  and 
alveolar  processes,  these  outlines  become  less  apparent.  As^the  period 
of  dentition  approaches,  a  slight  ridge  on  the  summit  of  each  jaw  is  seen, 
which  is  attributed  to  the  dipping  down  of  the  process  of  epithelium 
which  forms  the  enamel  organ.  Prior  to  the  sixth  month  of  age  (the 
period  at  which  first  dentition  commences),  small  prominences  are  ob- 
served on  the  summits  of  the  alveolar  processes,  which  gradually  become 
more  distinct  and  almost  as  light  in  color  as  the  teeth  themselves. 
As  soon  as  the  tooth  has  penetrated  the  mucous  membrane,  the  latter 
contracts  so  as  to  permit  the  crown  of  the  tooth  to  project  above  its  level. 
The  deciduous  teeth  begin  to  erupt  at  the  age  of  six  months,  and  at 
the  age  of  two  years  and  a  half  all  of  the  first  set  have  appeared,  the 


DENTITION.  1 63 

corresponding  teeth  of  the  two  sides  of  the  jaw  erupting  at  the  same 
time.  The  two  inferior  central  incisors  appear  at  the  age  of  six  or 
seven  months,  in  the  order  in  which  they  are  named,  followed  by  the 
superior  central  incisors,  the  superior  lateral  incisors,  the  inferior  lateral 
incisors,  the  four  first  molars,  the  four  canines,  and  last,  the  four  second 
molars.  The  usual  order  of  the  eruption  of  the  deciduous  teeth  is  as 
follows : — 

Central  incisors  between  the    5th  and    8th  months. 

Lateral  incisors         "         "      7th  and  10th       " 

Canines  "         "    12th  and  16th       "  • 

First  molars  "         "    14th  and  20th       " 

Second  molars  "         "    20th  and  36th       " 

The  lower  teeth  generally  precede  the  upper  teeth  by  a  few  weeks, 
appearing  in  the  same  order. 

This  order,  however,  is  not  invariably  followed,  for  teeth  may  be 
prematurely  erupted  so  as  to  be  seen  at  birth.  But  the  cases  of 
retarded  eruption  are  much  more  common  than  those  of  premature 
eruption,  owing  to  constitutional  debility  or  the  existence  of  some  con- 
stitutional disease. 

Henry  Sewell,  M.  R.  c.  8.,  gives  the  following  concise  description  of 
the  process  of  eruption :  "  The  eruption  of  the  teeth  is  a  process  of 
gradual  elongation  of  the  teeth  on  the  one  hand,  and  the  simultaneous 
absorption  of  the  super-imposed  tissue  op  the  other.  The  absorption 
commences,  first,  in  the  overhanging  margins  and  front  walls  of  the 
alveoli,  which  gradually  disappear  until  room  is  afforded  for  the  pas- 
sage of  the  advancing  tooth.  The  growth  of  the  tooth  keeps  pace  with 
this  absorption,  and  the  crown  of  the  tooth  at  length  pressing  against 
the  membranous  coverings,  these  undergo  atrophy,  and  becoming  by 
degrees  thinner,  and  at  last  transparent,  give  way  and  disclose  the 
advancing  crown." 

The  exact  relation  of  dentition  to  infantile  diseases  is  not  generally 
recognized,  and  many  affections  have  been  erroneously  ascribed  to  this 
process. 

There  is  no  doubt,  however,  that  the  condition  of  the  system  at  the 
period  of  first  dentition  is  such  that  the  infant  is  very  susceptible  to 
nervous  impressions,  and  hence  the  symptoms  of  any  constitutional 
disease  that  may  be  present  are  greatly  aggravated. 

The  evolution  of  the  teeth  is  commonly  attended  with  more  or  less 
inflammation  of  the  parts  in  relation  with  the  dental  follicles,  and  this 
turgescence  is  greater  with  some  teeth  than  with  others ;  sometimes  it 
is  present  to  such  a  degree  that  .the  gums  are  greatly  swollen  and 
extremely  tender,  presenting  a  very  red  appearance,  more  so  than  in 
ordinary  dentition. 


164  DENTAL  PATHOLOGY,  THEEAPEUTICS. 

The  salivary  secretion,  which  is  very  scanty  prior  to  the  period  of 
the  eruption  of  the  teeth,  always  increases  as  dentition  approaches, 
and  in  cases  of  difficult  dentition,  becomes  very  profuse.  A  decided 
form  of  stomatitis  may  be  present,  and  in  some  cases,  even  abscesses 
have  formed,  w'hich  could  only  be  relieved  by  incisions.  As  a  general 
rule  the  degree  of  irritation  present  depends  upon  the  number  of  teeth 
erupting,  but  owing  to  the  difference  of  susceptibility,  one  tooth  may 
give  rise  to  more  irritation  than  the  simultaneous  eruption  of  several 
teeth  will  in  other  cases. 

A  perfectly  healthy  child,  properly  cared  for,  may  erupt  its  teeth 
with  little  or  no  suffering,  although  there  may  be  some  restlessness, 
a  slight  decrease  of  appetite,  and  a  slight  elevation  of  the  temperature 
of  the  mouth.  At  other  times  a  mere  local  uneasiness  may  be  experi- 
enced, which  will  induce  the  infant  to  place  its  finger  in  the  mouth,  or 
to  bite  upon  some  foreign  substance,  which  apparently  affords  relief. 
In  such  cases  as  these  the  processes  of  the  development  of  the  teeth, 
and  the  absorption  of  the  tissues  confining  them,  are  equal,  and  the 
result  is  that  the  teeth  perforate  the  gum  without  causing  either  pain 
or  irritation.  Where,  however,  there  is  a  difference  in  the  progress 
between  the  growth  of  the  teeth  and  the  absorption  of  the  opposing 
structui'es,  then  these  different  forces  produce  irritation,  and  a  difficult 
dentition  results. 

The  immediate  cause  of  the  irritation  is  conceded  to  be  due  to  the 
downward  pressure  of  the  root  upon  the  nerves  and  vessels  of  the  pulp 
of  the  tooth,  such  pressure  being  caused  by  the  opposing  gum,  and 
giving  rise  to  congestion  and  swelling,  which  have  the  effect  of  in- 
creasing the  induration  of  the  opposing  tissues.  Constitutional  as  well 
as  local  symptoms  result  from  such  irritation,  some  of  which  are  of 
the  most  serious  character.  The  cerebro-spinal  system  may  become 
affected,  giving  rise  to  restlessness,  sleeplessness,  pain  in  the  head, 
convulsions  or  paralysis  ;  also  the  res^Diratory  system,  a  condition  which 
is  manifested  by  cough,  catarrh,  bronchitis,  pneumonia,  or  spasmodic 
croup ;  also  the  alimentary  canal,  when  there  may  be  nausea,  vomiting, 
loss  of  appetite  or  diarrhoea ;  also  the  skin  may  become  affected,  and 
such  forms  of  skin  disease  may  manifest  themselves  as  eczema,  acne, 
etc.  Therefore  the  period  of  dentition  may  be  a  dangerous  one,  for 
many  infants  die  at  this  time,  either  from  convulsions,  from  whooping 
cough,  or  cholera  infantum.  Difficult  dentition  is  more  frequently  a 
predisposing  than  a  direct  cause  of  infantile  convulsions.  At  such  a 
period  a  sensitive  state  of  the  nervous  system,  or  an  afflux  of  blood  to 
the  head,  may  result  in  convulsions,  although  such  an  affection  may  be 
the  direct  consequence  of  the  irritation  caused  by  the  efforts  of  several 
teeth  to  erupt  at  the  same  time,  especially  in  the  case  of  weakly  children. 


DENTITION.  165 

The  premonitory  symptoms  of  couvulsions  are  depression,  restless- 
ness, and  fVetfulness  for  some  days  before  the  paroxysm;  the  eyes 
have  a  wild,  unnatural  appearance,  the  sleep  is  disturbed,  and  some- 
times there  is  unusual  heat  of  the  head,  with  a  sudden  startiuff  or 
twitching  of  the  limbs.  In  general  convulsions,  the  paroxysm  is  char- 
acterized by  a  hot  head  during  its  early  stage,  and  a  flushed  face,  while 
in  sympathetic  convulsions  the  head  is  cool  and  the  face  pallid  ;  the 
pulse  is  accelerated,  as  well  as  the  respiration,  which  is  also  irregular, 
especially  if  the  respiratory  muscles  are  involved,  which  is  usually  the 
case.  The  muscles  of  the  face,  eyes  and  eyelids,  and  limbs,  are  in  a 
state  of  rapid  involuntary  cntraction  and  relaxation;  the  features  are 
distorted  ;  the  mouth  is  drawn  out  of  shape,  and  the  teeth  become 
tightly  closed,  owing  to  the  tonic  contraction  of  the  masseter  muscles ; 
and  if  the  paroxysm  is  prolonged,  frothy  saliva  may  issue  from  the 
lips. 

The  eyelids  are  usually  open,  and  in  severe  cases  the  pupils  of 
the  eyes  are  concealed  under  the  upper  lids,  or  the  eyeballs  may  be 
forcibly  drawn  from  side  to  side.  The  head  is  strongly  retracted,  or 
turned  to  one  side;  the  thumbs  and  fingers  are  convulsively  flexed, 
so  that  the  former  are  turned  across  the  palms  and  covered  by  the 
fingers ;  the  great  toe  is  adducted  and  the  other  toes  are  flexed,  and 
with  the  legs  move  spasmodically  ;  consciousness  is  lost.  The  duration 
of  the  paroxysm  varies  from  a  few^  minutes  to  several  hours,  generally 
averaging  from  five  to  fifteen  minutes ;  and  when  it  terminates 
favorably,  the  spasmodic  movements  gradually  cease,  and  are  followed 
by  a  deep  inspiration  and  quiet  or  sleep,  with  a  return  of  conscious- 
ness. The  temperature  and  respiration  become  natural,  although  dull- 
ness and  bewilderment  of  mind  may  continue  for  several  hours.  In 
severe  cases,  the  respiration  is  so  embarrassed  and  the  circulation  so 
retarded  that  congestion  of  various  organs  results.  Death  does  not 
usually  occur  from  one  paroxysm,  but  from  several  at  intervals, 
during  the  last  of  which  convulsive  movements  cease,  and  there 
is  no  return  of  consciousness ;  the  limbs  grow  cold,  the  pulse  feeble, 
and  coma  supervenes. 

The  treatment  of  convulsions  consists  in  placing  the  feet,  as  soon  as 
possible,  in  hot  water,  to  which  mustard  is  added  ;  or  a  warm  bath  may 
be  used;  such  measures  having  a  soothing  efiect  upon  the  nervous  sys- 
tem, and  causing  muscular  relaxation  and  derivation  of  blood  from 
the  cerebro-spinal  axis.  They  also  prevent  passive  congestion  and 
oedema  of  the  brain  and  lungs.  Cold  applications',  in  the  form  of  a 
cloth  frequently  wrung  out  in  cold  water,  should  be  made  to  the  head, 
to  reduce  its  temperature,  which  will  have  the  effect  of  contracting  the 
vessels  and  membranes  of  the  head,  and  diminishing  the  cerebral  con- 


166  DENTAL  PATHOLOGY,  THERAPEUTICS. 

gestion.  An  aperient,  is  useful,  unless  there  has  been  previous  diarrhoea. 
An  enema  of  soap  and  water  will  produce  free  and  speedy  evacuation, 
as  it  is  often  necessary  to  relieve  the  digestive  canal  of  irritating  sub- 
stances. 

For  the  relief  of  the  paroxysm,  and  to  lessen  its  duration,  chloroform 
has  been  successfully  employed  as  an  anaesthetic,  but  as  it  is  a  danger- 
ous agent,  the  bromide  of  potassium  is  preferable,  in  doses  of  three 
grains  for  a  child  one  year  of  age,  or  four  or  five  grains  for  a  child  of 
two  or  three  years  of  age,  dissolved  in  cold  water,  and  administered 
every  ten  minutes;  after  the  convulsions  cease,  there  should  be  longer 
intervals  between  the  doses.  In  very  severe  cases,  where  the  bromide 
of  potassium  may  not  act  with  the  required  promptness,  the  hydrate  of 
chloral  may  be  employed  in  doses  of  five  grains  for  a  child  of  one  year 
of  age,  and  ten  grains  for  one  of  four  years  of  age,  dissolved  in  two  or 
three  drachms  of  water,  and  injected,  by  means  of  a  small  syringe,  into 
the  rectum. 

This  remedy  is  generally  successful  in  controlling  the  spasmodic 
movements  in  five  or  ten  minutes,  unless  recovery  is  impossible.  During 
such  premonitory  symptoms  of  difficult  dentition  as  fretfulness  and 
nervous  excitement,  the  bromide  of  potassium  is  a  useful  and  safe 
remedy.  Demulcent  and  soothing  lotions  are  useful  to  reduce  the 
swelling  and  tenderness  of  the  gums ;  and  an  ivory  or  rubber  ring,  for 
the  child  to  bite  upon,  will  afi()rd  great  relief. 

The  practice  of  rubbing  the  gums  with  a  thimble  or  ring  is  injurious, 
as  the  swelling  and  tenderness  are  increased. 

Unless  the  tooth  is  on  the   point  of  protruding,  the  operation  of 
lancing  the  gum  is  by  many  thought  to  be  unnecessaiy,  for  the  reason 
that  the  gum  is  not  rendered  tense  by  the  pressure  of  the  advancing 
tooth,  and  too  much  importance  has  been  attached  to  the  supposed  ten- 
sion and  resistance  of  the  gum. 

When  the  symptoms  are  local  and  the  gums  are  somewhat  congested 
and  swollen,  scarifying  them  lightly  with  a  very  sharp  lancet  will  often 
afibrd  relief;  but  if  the  gums  are  very  tender,  this  operation  should  not 
be  performed. 

Others,  again,  advocate  the  operation  of  lancing  the  gums  in  difficult 
dentition,  even  when  no  single  local  indication  exists  in  the  mouth, 
by  making  free  incisions  over  the  teeth  whose  eruption  is  anticipated, 
the  cuts  extending  through  the  gum  to  the  presenting  surface  of 
the  tooth,  and  thus  affi)rding  manifest  and  complete  relief.  Such 
objections  against  lancing  the  gums,  as  the  infliction  of  great  pain, 
and  uncontrollable  hemorrhage,  are  of  little  moment,  as  is  also  the 
assumed  increased  resistance  of  cicatricial  tissue ;  for,  although  the 
wound  made  by  the  lancet   should   heal   before   the   appearance   of 


DENTITION.  167 

the  tooth,  this  cicatricial  tissue  is  easier  absorbed,  and  consequently 
less  resistant. 

For  lancing  the  gum  over  an  incisor,  a  single  incision  in  the  line  of 
the  arch  will  answer ;  the  molars  generally  require  a  crucial  incision, 
and  the  gum  of  the  canines,  even  after  the  point  of  the  cusp  has 
emerged,  may  require  severance  on  the  lateral,  anterior  and  pos- 
terior surfaces,  in  order  to  relieve  the  tension  and  liberate  these  teeth. 
'The  illustrations  (Fig.  73),  show  the  necessary  incisions  for  the  different 
classes  of  teeth.  Should  undue  bleeding  result  from  such  an  operation, 
it  can  be  arrested  by  means  of  a  little  finely  powdered  alum  applied  to 
the  incisions ;  should  such  a  remedy  fail,  more  powerful  astringents 
or  styptics  can  be  employed,  but  their  use  is  seldom  necessary. 

It  is  not  unusual  for  some  children  to  be  affected  with  diarrhoea 
during  the  period  of  dentition,  and  which  may  be  accompanied  with 
irritability  of  the  stomach.  But  there  are  often  other  causes  for  this 
affection  than  those  which  can  be  attributed  to  dentition,  such  as 
improper  food  and  clothing,  residence  in  unhealthy  localities,  and  expo- 
sure to  cold. 

Fig.  73. 


-.?' 


.^ 


The  diarrhoea  should  be  controlled  by  proper  remedies,  capable  of 
reducing  the  number  of  evacuations  to  two  or  three  daily,  as  a  greater 
number  may  result  in  danger  to  the  child.  The  treatment  of  the 
diarrhoea  of  dentition  consists  in  a  change  in  the  diet,  the  adoption  of 
hygienic  measures,  and,  when  medicines  are  necessary,  the  administra- 
tion of  the  milder  purgatives  in  small  doses.  Where  the  dejections 
are  acid,  as  is  shown  by  the  green  color,  half  a  teaspoonful  to  one 
teaspoonful  of  castor  oil  or  calcined  magnesia  will  prove  beneficial. 
According  to  West,  if  there  be  neither  much  pain  nor  tenesmus,  and 
the  evacuations,  though  watery,  are  fecal,  and  contain  little  mucus 
and  no  blood,  very  small  doses  of  the  sulphate  of  magnesia  and  tinc- 
ture of  rhubarb  are  more  useful  than  any  other  remedy. 

R.   Magnesiae  sulphatis 3J 

Tinct.  rhei 3J 

Syr.  zingiberis 5J 

Aqoae  carui .^ix.     M. 

SiG.  —One  drachm  three  times  a  day,  for  children  one  year  old. 


168  DENTAL  PATHOLOGY,  THERAPEUTICS. 

For  the  diarrhoea  of  infants  due  to  indigestion,  and  attended  with 
acidity,  Prof  J.  L.  Smith  recommends  the  following : — 

R.     Pulv.  ipecac gr.  ss 

Pulv.  rhei gr.  ij 

Sodse  bicarb gr.  xij.     M. 

Divide  into  chart.  No.  xij.  One  powder  every  four  to  six  hours,  for  an  infant 
one  year  old. 

The  same  author  also  recommends  the  following  in  the  non-inflam- 
matory diarrhoea  of  infants  : — 

B.     Tinct.  opii  deodorat gtt.  xvj 

Bismuth,  subnitrat 3  ij 

Syr.  simplic ^ss 

Mistur.  cretse giss.     M. 

Shake  well,  and  give  one  teaspoonful,  from  three  to  four  hours. 

For  the  skin  affection  attending  dentition,  such  as  eczema  in  the 
acute  form,  with  a  watery  discharge  and  an  irritable  skin,  oxide  of  zinc, 
used  as  a  dusting  powder,  will  prove  serviceable,  but  the  parts  should 
not  be  washed  with  water. 

When  the  discharge  is  thicker  and  more  purulent,  and  forms  scabs, 
they  may  be  removed  by  bathing  the  part  with  oil  and  washing  it  with 
soap  and  water,  and  a  salve  applied,  composed  of  equal  parts  of  vaseline 
and  simple  lead  plaster ;  or  less  of  the  lead  plaster  may  be  used  with 
the  vaseline,  if  the  salve  should  prove  too  strong ;  or  an  ointment  may 
be  employed,  composed  of  oxide  of  zinc,  five  grains,  and  simple  salve, 
one  ounce. 

When  the  gum  over  an  erupting  tooth  appears  swollen  and  con- 
gested, and  at  length  ulcerates,  even  after  the  tooth  is  protruding,  a 
condition  to  which  the  appellation  "  odontitis  infantum"  has  been  ap- 
plied, the  ulcers  may  be  touched  with  a  crystal  of  alum,  and  a  lotion 
composed  of  sage  tea  and  honey  used,  with  decided  advantage.  For  a 
sloughing  condition  of  the  mucous  membrane  over  an  erupting  tooth, 
the  careful  application  of  strong  carbolic  acid  will  prove  efficient. 

SECOND   DENTITION. 

The  design  of  nature  is  to  preserve  the  deciduous  teeth  until  their 
roots  are  absorbed  and  they  become  loose,  and  are  removed  to  make 
room  for  their  permanent  successors.  But  the  eruption  of  the  permanent 
teeth  begins  before  any  of  the  deciduous  teeth  are  removed.  Between 
the  ages  of  five  and  a  half  and  six  years,  the  first  permanent  molars 
make  their  appearance ;  hence  they  are  commonly  called  "  sixth- 
year  molars,"  and  their  germs,  with  those  of  the  remaining  permanent 
teeth,  are  progressing  with  the  development  of  the  deciduous  teeth. 


H 


SECOND    DENTITION. 


169 


When  the  permanent  teeth  are  developing,  and  their  crowns,  on 
account  of  the  growth  of  the  roots,  are  approaching  the  alveoli  of  the 
deciduous  teeth,  a  process  of  absorption  commences,  by  which  the  roots 
of  the  latter  teeth  are  gradually  destroyed,  the  dissolving  process  going 
on  until  only  the  crowns  of  the  deciduous  ones  remain.  The  process  of 
absorption  affects  the  roots  of  the  deciduous  teeth  in  the  order  corres- 
ponding to  their  development  and  eruption  ;  the  inferior  central  incisors 
are  first  shed,  then  the  superior  central  incisors,  then  the  lateral  in- 
cisors ;  and  this  order  is  preserved  until  all  of  the  deciduous  teeth  have 
been  removed  or  have  become  so  loose  that  they  are  easily  extracted. 

The  absorption  process  commences  in  the  alveoli  of  the  deciduous 
teeth,  and  then  attacks  the  apices  of  their  roots,  and  in  some  cases 

Fig.  74. 


ILLUSTRATES   THE   JAWS   OF  A   CHILD     SIX   YEARS   OF   AGE,   RHOWINO    THE    RELATIONS    OF   THE   TWO   SETS 

OF   TEETH. 


progresses  until  it  involves  a  large  portion  of  the  crowns.  The  loss  of 
substance  commences  generally  upon  the  side  of  the  root,  near  the  apex, 
toward  the  advancing  crown  of  the  permanent  tooth,  and  the  surface 
of  the  rooi;  acted  upon  presents  pits,  grooves,  or  irregular  facets,  with 

yr  rough  surfaces  and  sharp  edges,  such  as  would  result  from  corrosion. 

'  If  a  deciduous  tooth  undergoing  this  process  of  absorption  be  extracted, 
a  loose,  spongy  substance  is  found  adherent  to  it,  which  Laforgue  and 
Bourdet  supposed  to  be  an  absorbent  organ  secreting  a  fluid  capable 
of  dissolving  the  tooth  structure.  According  to  Wedl,  a  fluid  is  secreted 
by  the  cells  of  this  organ  which  dissolves  the  hard  substance,  and 
referring  to  the  theory  held  by  some,  he  says  "  that  these  cells  are  of  a 


V 


170  DENTAL  PATHOLOGY,  THERAPEUTICS. 

parasitic  nature,  that  is  to  say,  that  the  dental  substances  are  eaten  up,  as 
it  were,  since  the  cells  absorb  the  latter,  and  he  remarks  that  "  possibly 
amoeboid  movements  may  be  the  occasion  of  the  wasting  of  the  tissues ;" 
he  is  also  of  the  opinion  that  the  organ  of  absorption  is  developed  from 
the  connective  tissue  of  the  root  membrane  of  the  deciduous  tooth. 
According  to  a  microscopic  examination  made  by  Mr.  Tomes,  the  sur- 
face of  this  absorptive  organ  is  made  up  of  peculiar  multiform  cells, 
each  one  being  composed  of  several  smaller  cells,  the  number  varying 
from  two  or  three  to  as  many  as  fourteen  or  fifteen. 

Some  have  regarded  the  method  employed  by  nature  for  the 
removal  of  the  roots  of  the  temporary  teeth  as  sui  generis,  but  there  is 
a  better  reason  for  considering  it  to  be  the  effect  of  an  inflammatory 
process  that  brings  about  a  proliferation  of  cell  growth,  which  may  at 
one  time  act  as  an  absorbent  and  at  another  be  reparative.  As  to  the 
precise  manner  in  which  these  cells  of  the  absorbent  organ  act,  much 
remains  to  be  learned,  but  that  it  is  a  physiological  process,  and  occa- 
sioned by  the  action  of  cells  known  as  "osteoclasts,"  or  "odontoclasts," 
and  is  not  a  mechanical  force,  is  now  quite  generally  admitted.  These 
cells  secrete  what  has  been  termed  "  a  soluble  ferment,"  or  "  fluid  of 
exudation,"  which  dissolves  out  the  lime  salts  from  the  hard  tissues  with 
which  it  comes  in  contact,  the  surface  acted  upon  presenting  a  series  of 
pits  and  cup-shaped  depressions. 

Dr.  C.  N.  Peirce,  in  an  excellent  article,  entitled  "Calcification  and 
Decalcification  of  the  Teeth,"  *  and  which  is  illustrated  by  the  follow- 
ing instructive  figures  (Fig.  75),  in  treating  of  the  absorption  or  decal- 
cificatic^  of  the  roots  of  the  deciduous  teeth,  regards  this  process  "  as 
being  both  physiological  and  somewhat  obscure;"  and  he  further 
states : — 

"The  evidence  that  it  is  the  result  of  a  physiological  action  is  the 
fact  that  it  matters  not  to  what  extent  absorption  has  progressed,  the 
very  moment  vitality  of  the  pulp  ceases,  that  instant  this  retrograde 
metamorphosis  terminates.  What  induces  this  molecular  dissolution  it 
is  difficult  to  state,  though  the  several  conditions  which  are  always 
present  are  readily  recognized ;  but  the  part  they  play  is  so  obscure 
that  it  is  not  readily  ascertained.  The  manner  of  its  commencement 
when  successful — always  at  the  end  of  the  root — and  the  presence  of  a 
vascular  papilla  in  close  proximity  to  the  absorbing  surface,  are,  with 
the  retention  of  pulp  vitality,  three  essential  accompaniments,  and  the 
absence  of  any  one  of  them  would  militate  against  the  completion  of 
the  process. 

"  The  statement  that  the  presence  and  pressure  of  the  permanent 
tooth  are  essential,  cannot  be  sustained,  for  frequently  the  decalcifica- 
*  Dental  Cosmos,  August,  1884. 


^   H-  K>    W 


l=-C       B*     D* 


CO    t-s 

B   B 


172 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


tion  of  the  deciduous  tooth  is  successfully  accomplished  in  the  absence 
of  its  successor  ;  and  again,  how  often  do  we  find  the  permanent  tooth 
impacted  against  or  within  the  bifurcated  roots  of  the  deciduous  molar, 
or  pressing  down  by  the  side  of  its  single-rooted  predecessor,  both 
being  more  or  less  displaced  by  the  persistence  of  the  deciduous  tooth 
without  absorption.  That  the  organ  has  served  its  purpose,  and  that 
the  nourishment  which  had  previously  been  appropriated  by  it  is 
diverted  or  relegated  to  its  successor,  is  probably  the  most  plausible 
explanation  we  can  give  of  this  interesting  physiological  process." 

The  average  time  and  order  for  the  eruption  of  the  permanent  teeth 
are  as  follows : — 


5  to     6  years 

6 

'•     8      " 

7 

"     9      " 

9 

"   10      " 

10 

"  12      " 

11 

"  13      " 

12 

"  14      " 

17 

"  21      " 

ion  oJ 

Fthe 

permanent 

First  molars, 

Central  incisors, 

Lateral  incisors. 

First  bicuspids, 

Second  bicuspids 

Canines, 

Second  molars, 

Third  molars,  or  wisdom  teeth. 


Usually  but  little  trouble  attends  the  eruption  of  the  permanent  teeth, 
with  the  exception  of  the  third  molars  of  the  lower  jaw,  which  may 
cause  considerable  trouble  and  suffering,  on  account  of  their  being 
crowded  between  the  second  molar  and  the  ramus  or  ascending  portion 
of  the  jaw,  the  space  left  being  insufficient  to  accommodate  the  third 
molar.  Inflammation  from  such  a  cause  may  extend  to  the  soft  tissues, 
such  as  the  muscles,  and  render  the  act  of  swallowing  difficult  and 
painful,  and  that  of  mastication  impossible.  The  inflammation  thus 
caused  may  also  terminate  in  suppuration,  and  the  pus  discharge  at 
remote  points,  internal  or  external.  Such  maladies  as  neuralgia,  hys- 
teria, epilepsy,  St.  Vitus'  dance,  disordered  vision,  earache,  deafness, 
tetanus,  etc.,  have  been  caused  by  the  eruption  of  the  third  molar. 
Occasionally  the  eruption  of  the  molars  anterior  to  the  third  molars 
may  be  attended  with  some  constitutional  disturbance,  such  as  head- 
ache, slight  neuralgic  pains,  impaired  apj)etite ;  and  also  local  symp- 
toms, such  as  swollen  gums,  increased  heat  of  mouth,  and  an  increased 
flow  of  saliva.  The  extraction  of  the  third  molar  may  be  necessary  in 
some  cases ;  in  others,  that  of  the  second  molar,  although  the  removal 
of  a  carious  first  molar  may  sometimes  relieve  the  crowded  condition 
of  the  arch,  when  the  trouble  is  owing  to  a  want  of  space  between  the 
second  molar  and  the  ramus  of  the  jaw.  The  lancing  of  the  gum  over  a 
third  molar  not  yet  protruded  often  relieves.  The  most  common 
period  of  sufiering  from  second  dentition,  apart  from  that  of  the  third 


THIED   DENTITION. 


173 


molar,  is  from  the  tenth  to  the  thirteenth  year,  and  it  is  characterized 
by  such  affections  as  obstinate  and  protracted  cough,  with  paroxysms  of 
long  duration,  also  diarrhoea,  wasting  of  flesh,  nervous  diseases,  loss  of 
spirits,  headache,  and  morbidly  sensitive  and  painful  eyes. 

The  obstinate  cough  has  disappeared  when  the  molar  teeth  pierced 
the  gums  ;  and  a  mixture  of  iron  and  nitric  acid  was  successful  in 
immediately  curing  a  patient  of  seven  years  of  age  in  the  jDractice  of 
Dr.  James  Jackson,  who  recommends  the  following  remedies  as  being 
most  useful : — 

"  First,  a  relief  from  study  or  from  regular  tasks,  yet  using  books  so 
far  as  they  afford  agreeable  occupation  or  amusement.  Second,  exercise 
in  the  open  air,  preferring  the  mode  most  agreeable  to  the  patient,  and 
in  more  grave  cases  the  removal  from  town  to  country." 

Fig.  76  represents  an  instrument,  the  invention  of  Mr.  Woodhouse, 
and  introduced  by  Dr.  L.  D.  Shepai^d,  designed  for  the  removal  of  the 

Fig.  76. 


overlying  gum  which  covers  the  masticating  surfaces  of  the  first  and 
third  molars,  very  often  for  months  after  the  cusps  have  appeared 
through  the  gum,  and  thus  promotes,  if  it  does  not  cause,  the  decay  so 
frequently  accompanying  these  teeth  upon  their  eruption.  An  incision 
#-made  with  a  lancet,  through  the  gum,  along  the  anterior  margin  of 
the  tooth,  and- the  thin  flat  blade  of  the  cutter  is  inserted;  then,  by 
closing  the  handles,  the  section  of  gum  the  size  of  the  blade  is  instantly 
removed.  The  operator  will  find  this  process  much  more  efiectual, 
and  far  easier  to  the  patient,  than  the  usual  practice  of  cutting  the  gum 
in  diflerent  directions. 

THIRD     DENTITION. 

That  nature  sometimes  makes  an  effort  to  produce  a  third  set  of 
teeth  is  a  fact  which,  however  much  it  may  be  disputed,  is  now  so 
well  established,  that  no  room  is  left  for  cavil  or  doubt. 


174  DEXTAL  PATHOLOGY,  THERAPEUTICS. 

The  following  interesting  particulars  are  taken  from  "  Good's  Study 
of  Medicine":— 

"  We  sometimes,  though  rarely,  meet  with  playful  attempts  on  the 
part  of  nature  to  reproduce  teeth  at  a  very  late  period  of  life,  and 
after  the  j)ermanent  teeth  have  been  lost  by  accident  or  by  natural 
decay. 

"  This  most  commonly  takes  place  between  the  sixty-third  and 
eighty-first  year,  or  the  interval  which  fills  up  the  two  grand  climac- 
teric years  of  the  Greek  physiologist ;  at  which  period  the  constitution 
appears  occasionally  to  make  an  effort  to  repair  other  defects  than  lost 
teeth.     .     .     . 

"  For  the  most  part,  the  teeth,  in  this  case,  shoot  forth  irregularly, 
few  in  number,  and  without  proper  roots,  and,  even  where  roots  are 
produced,  without  a  renewal  of  sockets.  Hence,  they  are  often  loose, 
and  frequently  more  injurious  than  useful,  by  interfering  with  the 
uniform  line  of  indurated  and  callous  gums,  which,  for  many  years 
perhaps,  had  been  employed  as  a  substitute  for  the  teeth.  A  case  of 
this  kind  is  related  by  Dr.  Bisset,  of  Knayton,  in  which  the  patient,  a 
female  in  her  ninety-eighth  year,  cut  twelve  molar  teeth,  mostly  in  the 
lower  jaw,  four  of  which  were  thrown  out  soon  afterward,  while  the 
rest,  at  the  time  of  examination,  were  found  more  or  less  loose. 

"  The  German  Epheraerides  contain  numerous  examples  of  the  same 
kind ;  in  some  of  which  teeth  were  produced  at  the  advanced  age  of 
ninety,  a  hundred,  and  even  a  hundred  and  twenty  years.  One  of  the 
most  singular  instances  on  record  is  that  given  by  Dr.  Slade,  which 
occurred  to  his  father,  who,  at  the  age  of  seventy-five,  reproduced  an 
incisor,  lost  twenty-five  years  before,  so  that,  at  eighty,  he  had  hereby 
a  perfect  row  of  teeth  in  both  jaws.  At  eighty-two,  they  all  dropped 
out  successively ;  two  years  afterward,  they  were  all  successively  re- 
newed, so  that  at  eighty-five  he  had  once  more  an  entire  set.  His 
hair,  at  the  same  time,  changed  from  a  white  to  a  dark  hue ;  and  his 
constitution  seemed,  in  some  degree,  more  healthy  and  vigorous.  He 
died  suddenly,  at  the  age  of  ninety  or  a  hundred. 

"  Sometimes  these  teeth  are  produced  with  wonderful  rapidity ;  but  in 
such  cases  with  very  great  pain,  from  the  callosity  of  the  gums  through 
which  they  have  to  force  themselves.  The  Edinburgh  Medical  Com- 
mentaries supply  us  with  an  instance  of  this  kind.  The  individual  was 
in  his  sixty-first  year,  and  altogether  toothless.  At  this  time  his  gums 
and  jaw  bones  became  painful,  and  the  pain  was  at  length  excruciating. 
But  within  the  space  of  twenty-one  days  fi'om  its  commencement,  both 
jaws  were  furnished  with  a  new^  set  of  teeth,  complete  in  number." 

A  late  physician  of  Baltimore  informed  the  author,  in  1838,  that  an 
example  of  third  dentition  had  come  under  his  own  observation.     The 


THIRD   DENTITION.  175 

subject,  a  female,  at  the  age  of  sixty,  he  assured  him,  erupted  au  entire 
new  set  in  each  jaw. 

The  following  extract  of  a  letter  from  a  professional  friend,*  de- 
scribes another  very  interesting  case  : — 

"I  have  just  seen  a  case  of  third  dentition.  The  subject  of  this 
'playful  freak  of  nature,'  as  Dr.  Good  styles  it,  is  a  gentleman  residing 
in  the  neighborhood  of  Coleman's  Mill,  Caroline  County,  Virginia. 
He  is  now  in  his  seventy-eighth  year,  and  as  he  playfully  remarked, 
'  is  just  cutting  his  teeth.'  There  are  eleven  out,  five  in  the  upper  and 
six  in  the  lower  jaw.  Those  in  the  upper  jaw  are  two  central  incisors, 
one  lateral  and  two  bicuspids,  on  the  right  side.  Those  in  the  lower 
are  the  four  incisors,  one  cuspid  and  one  molar.  Their  appearance  is 
that  of  bone,  extremely  rough,  without  any  coating  or  enamel,  and  of 
a  dingy  brown  color." 

Two  cases  somewhat  like  the  foregoing  have  come  under  the  author's 
observation.  The  subject  of  the  first  was  a  shoemaker,  Mr.  M.,  of 
Baltimore,  who  erupted  a  lateral  incisor  and  cuspid  at  the  age  of  thirty. 
Two  years  before  this  time  he  had  been  badly  salivated,  and,  in  con- 
sequence, lost  four  upper  incisors  and  one  cuspid.  The  alveoli  of  these 
teeth  exfoliated,  and  at  the  time  he  first  saw  him,  were  entirely  de- 
tached from  the  jaw,  and  barely  retained  in  the  mouth  by  their  adhe- 
sion to  the  gums.  On  removing  them,  he  found  two  white  bony  pro- 
tuberances, which,  on  examination,  proved  to  be  the  crowns  of  an  incisor 
and  cuspid.  They  were  perfectly  formed,  and  though  much  shorter  than 
the  other  teeth,  yet  up  to  1845  they  remained  quite  firm  in  the  jaw. 

The  subject  of  the  other  case  was  a  lady  residing  near  Fredericks- 
burg, Virginia,  who  erupted  four  right  central  incisors  of  the  upper 
jaw  successively.  One  of  her  temporary  teeth,  in  the  first  instance, 
had  been  permitted  to  remain  too  long  in  the  mouth,  and  a  permanent 
central  incisor,  in  consequence,  came  out  in  front  of  the  dental  arch. 
To  remedy  this  deformity,  the  deciduous  incisor  was,  after  some  delay, 
removed;  and  about  two  years  after,  the  permanent  tooth,  not  having 
fallen  back  into  its  proper  place,  was  also  extracted.  Another  two 
years  having  elapsed,  another  tooth  came  out  in  the  same  place  and  in 
the  same  manner,  and,  for  similar  reasons,  was  also  removed.  To  the 
astonishment  of  the  lady  and  her  friends,  a  fourth  incisor  made  its 
appearance  in  the  same  place,  two  years  and  a  half  after  the  extraction 
of  the  first  permanent  tooth.  When  it  had  been  out  about  eighteen 
mouths,  the  author  was  called  in  by  the  lady,  who  wished  him,  if  pos- 
sible, to  adjust  it.  Finding  that  it  could  not  be  brought  within  the 
dental  circle,  he  advised  her  to  have  it  extracted,  and  an  artificial 
tooth  placed  in  the  proper  place  in  the  arch. 
*  Dr.  J.  D.  McCabe. 


176  DENTAL  PATHOLOGY,  THERAPEUTICS. 

In  the  second  number  of  the  eighth  vohime  of  the  "American  Jour- 
nal of  Dental  Science,"  the  history  of  a  case  of  four  successive  denti- 
tions of  the  upper  central  incisors  is  given.* 

It  is  said  that  the  efforts  made  by  nature  for  the  production  of  a 
third  complete  set  of  teeth  are  so  great  that  they  exhaust  the  remaining 
energies  of  the  system,  and,  as  a  consequence,  that  occurrences  of  this 
kind  are  generally  soon  followed  by  death. 

Concerning  the  manner  of  the  origin  and  formation  of  teeth  of  third 
dentition,  adopting  Wedl's  views,  germs  may  lie  dormant  for  many 
years  in  the  animal  organism,  until  they  are  subjected  to  favorable 
conditions  which  enable  them  to  develop.  The  crowns  of  such  teeth 
only  being  formed,  while  the  roots  are  stunted,  is  clearly  due  to  the 
small  depth  of  the  jaws  in  old  age. 

CHARACTERISTICS   OF   THE   TEETH. 

Most  dental  physiologists  have  observed  the  marked  diiFerences  that 
exist  in  the  appearances  of  the  teeth,  gums,  lips,  tongue,  and  secretions 
of  the  mouth  of  different  individuals ;  and  of  that  earthy  substance 
(commonly  called  tartar),  deposited  in  a  greater  or  less  abundance  on 
the  teeth  of  every  one;  and,  although  all  may  not  have  sought  their 
etiology,  many  have  had  occasion  to  notice,  at  least,  their  local  indica- 
tions, and  to  profit  by  the  information  which  they  have  thus  obtained. 
Nor  have  they  failed  to  observe  that  the  size,  color,  length  and 
arrangement  of  the  teeth  vary,  and  that  these  are  indications  of  their 
susceptibility  to  disease. 

There  are  five  principal  clases  or  descriptions  of  teeth,  each  of 
which  differs,  in  some  respects,  from  the  others,  a  knowledge  of  which 
is  very  essential  to  the  dental  practitioner,  in  order  that  he  may  de- 
termine their  liability  to  decay,  strength  of  attachment,  and  the  form 
and  size  of  their  roots. 

Class  First. — The  teeth  belonging  to  this  class  are  white,  with  a 
light  cream-colored  tinge  near  the  gum,  which  becomes  more  and 
more  apparent  as  the  subject  advances  in  age,  of  a  medium  size,  rather 
short  than  long,  with  thick,  square  edges  ;  those  of  each  class  of  uni- 
form dimensions,  and  very  hard.  This  description  of  the  teetli  is  most 
frequently  met  with  in  persons  of  sanguineous  temperament,  or,  at 
least,  those  in  whom  this  predominates  ;  they  rarely  decay,  and  gene- 
rally occupy  their  proper  position  in  the  dental  arch ;  the  most  common 
deviation,  and  one  almost  peculiar  to  this  class,  is  that  of  the  superior 
incisors  antagonizing  with  the  inferior,  causing  the  form  of  abrasion 
known  as  mechanical.  They  are  not  as  easily  acted  upon  by  corrosive 
agents,  and  caries  attacking  them,  usually  of  the  black  variety,  makes 
*  Dr.  W.  H.  Dwinelle. 


CHARACTERISTICS   OF   THE   TEETH.  177 

but  slow  progress,  and  often  exists  for  a  considerable  time  without 
causing  pain  or  inconvenience.  Operations  performed  upon  teeth  of 
this  class  are  those,  above  all  others,  on  which  we  can  predict  the 
most  perfect  success.  They  indicate,  if  not  perfect  health,  at  least 
a  state  which  bordered  very  closely  on  it  at  the  time  of  their  den- 
tinification. 

This  fi:i;st  description  of  teeth  is  occasionally  found  among  persons 
of  all  nations.  They  are  very  common  in  cold  and  temperate  climates, 
and  esj)ecially  in  the  middle  classes  of  the  inhabitants  of  England, 
Ireland  and  Scotland.  They  are  also  frequently  met  with  iu  some 
parts  of  the  United  States,  the  Canadas,  the  mountainous  districts  of 
Mexico,  and  so  far  as  we  have  had  an  opportunity  of  informing  our- 
self,  in  France,  Russia,  Prussia  and  Switzerland.  Those  who  have 
them  usually  enjoy  excellent  health,  and  are  seldom  troubled  with 
dyspepsia  or  any  of  its  concomitants.  It  is  this  kind  of  teeth  which, 
Lavater  says,  he  has  never  met  with  except  in  "  good,  acute,  candid, 
honest  men,"  and  of  whose  possessors  it  has  been  remarked,  that  their 
stomachs  are  always  willing  to  digest  whatever  their  teeth  are  ready  to 
masticate. 

In  confirmation  of  what  has  before  been  said  with  regard  to  the  in- 
fluence which  the  state  of  the  constitutional  health,  at  the  time  of  the 
solidification  of  the  teeth,  exerts  upon  the  susceptibility  of  these  organs 
to  morbid  impressions,  it  is  only  necessary  to  mention  the  fact,  well 
known  and  frequently  alluded  to,  of  the  early  decay  of  a  single  class, 
or  a  pair  of  a  •  single  class  of  teeth,  in  each  jaw,  while  the  rest,  pos- 
sessing the  characteristics  just  described,  remain  sound  through  life. 
Thus,  when  it  happens  that  a  child  of  excellent  constitution  is  affected 
with  any  severe  disease,  the  teeth  which  are  at  the  time  receiving  their 
earthy  salts  are  found,  on  their  eruption,  to  differ  from  those  which 
have  received  their  solid  material  at  another  time,  when  the  operations 
of  the  body  were  healthfully  performed.  Instead  of  having  a  white, 
smooth,  and  uniform  surface,  they  have  a  sort  of  chalky  aspect,  or  are 
faintly  tinged  with  blue,  and  are  rougher  and  less  uniform  in  their 
surfaces.  Teeth  of  this  description  are  very  susceptible  to  the  action 
of  corrosive  agents,  and,  as  a  consequence,  rarely  last  long. 

But,  not  willing  to  rest  the  correctness  of  these  views  upon  mere 
hypothesis,  we,  in  a  great  number  of  instances,  where  we  have  seen 
teeth  thus  varying  in  their  physical  appearance,  have  taken  pains  to 
inquire  of  those  who  had  an  opportunity  of  knowing  the  state  of  the 
general  health  of  the  individuals  at  the  different  periods  of  deutinifi- 
cation  ;  and  in  every  case  where  we  have  been  able  to  procure  the  de- 
sired information,  it  has  tended  to  the  confirmation  of  the  opinion  here 
advanced.  Nor  have  we  neglected  to  improve  the  many  opportunities 
12 


178  DENTAL  PATHOLOGY,  THERAPEUTICS. 

that  have  presented,  in  the  course  of  a  somewhat  extended  professional 
career,  of  making  these  observations. 

Although  the  operations  of  the  economy  are  so  secretly  carried  on 
that  it  is  impossible  to  comprehend  their  details  fully,  it  is  known  that 
the  phenomena  resulting  therefrom  are  influenced  and  modified  by  the 
manner  in  which  they  are  performed.  If  they  are  deranged,  the 
blood,  from  which  the  earthy  materials  forming  the  basis  of  all  the 
osseous  tissues  are  derived,  is  deteriorated,  and  furnishes  these  salts  in 
less  abundance  and  of  an  inferior  quality.  Hence,  teeth  that  solidify 
when  the  system  is  under  the  influence  of  disease,  do  not  possess  the 
chai-acteristics  necessary  to  enable  them  to  resist  the  assaults  of  corro- 
sive agents,  to  which  all  teeth  are  more  or  less  exposed,  and  which 
rarely  affect  those  that  receive  their  solidifying  ingredients  from  pure 
blood. 

The  calcareous  salts  of  these  organs  are  furnished  chiefly  by  the 
red  part  of  this  fluid,  the  gelatine  is  derived  from  the  white  or  serous 
part;  "  whence,"  as  Delabarre  remarks,  "it  results  that  the  solidity 
of  these  bones  varies  according  as  one  or  other  of  these  principles  pre- 
dominates," and  the  relative  proportions  of  these  are  regulated  by  the 
state  of  the  blood  at  the  time  the  teeth  are  undergoing  solidification. 

Class  Second. — Having  digressed,  thus  far,  we  shall  now  proceed  to 
notice  the  teeth  belonging  to  the  second  class.  They  have  a  faint, 
azure-blue  appearance ;  are  rather  long  than  short ;  the  incisors  are 
generally  thin  and  narrow,  the  centrals  being  frequently  a  little  longer 
than  the  laterals.  In  some  cases  the  lateral  incisors  are  very  small 
and  pointed.  The  cuspids  are  usually  round  and  pointed ;  the  bicus- 
pids and  molars  small  in  circumference,  with  prominent  cusps  and 
protuberances  upon  their  grinding  surfaces. 

Teeth  possessing  these  characteristics  are  usually  very  sensitive, 
caused,  doubtless,  by  a  superabundance  of  animal  matter,  and  are 
more  easily  acted  upon  than  teeth  of  the  first  class,  by  corrosive  agents, 
and  to  the  ravages  of  which,  unless  great  attention  is  paid  to  their 
cleanliness,  they  often  fall  early  victims.  The  variety  of  caries  almost 
peculiar  to  this  class  is  known  as  the  white,  the  parts  attacked  being 
rendered  soft  and  humid  ;  and  as  they  retain  their  natural  color,  it  but 
too  frequently  happens  that  such  teeth  are  almost  irretrievably  ruined 
before  its  presence  is  suspected.  They  are,  also,  more  frequently  af- 
fected with  atrophy,  or  have  upon  their  surfaces  white,  brown,  or  opaque 
spots,  varying  in  size  and  number  ;  several  are  sometimes  found  upon 
a  single  tooth,  and  in  some  instances  every  tooth  in  the  mouth  is  more 
or  less  marked  with  them. 

But  this  is  not  the  only  description  of  teeth  liable  to  be  affected 
with  this  disease.     These  spots  are   occasionally  met  with  on  teeth  of 


CHARACTERISTICS   OF   THE   TEETH.  179 

every  degree  of  density,  shape,  shade  and  size  ;  but  they  are,  probably, 
more  frequently  seen  on  teeth  of  the  second  class  than  on  those  first 
described  ;  besides  which,  it  often  happens  that  they  are  affected  with 
erosion  on  emerging  from  the  gums,  and  sometimes  so  badly  as  to  place 
either  their  restoration  or  preservation  beyond  the  reach  of  art.  This 
species  of  erosion,  or  that  which  occurs  previously  to  the  eruption  of 
the  teeth,  is  caused  by  some  diseased  condition  of  the  fluid  which  sur- 
rounds them  before  they  appear  above  the  gums,  and  is  denominated 
congenital. 

Teeth  like  those  now  under  consideration  are  indicative  of  a  weakly 
constitution,  of  a  temperament  considerably  removed  from  the  san- 
guineous, resembling  the  lymphatic,  and  of  blood  altogether  too  serous 
to  furnish  materials  such  as  are  necessary  for  building  up  a  strong  and 
healthy  organism.  They  are  more  common  to  females  than  to  males, 
though  many  of  the  latter  have  them.  They  are  met  with  among 
people  of  all  countries,  but  more  frequently  among  those  who  reside 
in  sickly  localities,  and  with  individuals  whose  systems  have  become 
enervated  by  luxurious  living.  In  Great  Britain  they  are  more  rare 
than  in  the  United  States,  and  those  who  have  them  seldom  attain  to 
a  great  age.  Nevertheless,  some,  under  the  influence  of  a  judicious 
regimen  and  a  salubrious  climate  though  innately  delicate,  do  acquire 
a  good  constitution,  and  live  to  a  great  age  ;  while  the  teeth,  less  for- 
tunate, unless  the  most  rigid  and  constant  attention  is  paid  to  the  use 
of  the  means  necessary  for  their  preservation,  generally  fall  early  vic- 
tims to  the  ravages  of  disease. 

Class  Third. — The  teeth  of  this  class,  though  differing  in  many  of 
their  characteristics  from  those  last  described,  are,  nevertheless,  not 
unlike  them  in  texture  and  sensibility  to  disease.  They  are  peculiar 
to  those  who  have  inhabited  a  scrofulous  habit  or  diathesis.  In  this 
state  of  the  sj^stem  we  find  a  sufficient  supply  of  blood,  but  it  is  usually 
of  a  pernicious  character  ;  the  whole  organism  is  affected  by  it  and 
rendered  very  susceptible  to  disease,  more  especially  to  that  class  super- 
induced by  cold.  Teeth  developed  under  constitutional  defects  of 
this  nature  are  larger  than  teeth  of  the  first  or  second  class  ;  their 
faces  are  rough  and  irregular,  with  protuberances  arising,  not  only 
from  the  grinding  surfaces  of  the  bicuspids  and  molars,  but  also  not 
unfrequentiy  from  their  sides,  with  correspondingly  deep  indentations. 
They  have  a  muddy  white  color.  The  crowns  of  the  incisors  of  both 
jaws  are  broad,  long,  and  thick.  The  posterior  or  palatine  surfaces 
of  those  of  the  superior  maxilla  are  rough  and  usually  deep  indented. 
In  the  majority  of  cases  their  arrangement  is  quite  regular,  though 
frequently  found  to  project.  The  alveolar  ridge  usually  describes  a 
broad  arch.     The  excess  in  size,  both  here  and  in  the  teeth,  seems  to 


180  DENTAL  PATHOLOGY,  THERAPEUTICS. 

consist  more  of  gelatin  than  calcareous  phosphate.  This  description 
of  teeth  decay  rapidly,  and  in  some  instances  appear  to  set  at  defiance 
the  resources  of  the  dentist.  They  are  liable  to  be  attacked  at  almost 
every  point,  but  more  particularly  in  their  indentations  and  approxi- 
mal  surfaces.  The  caries  to  which  these  teeth  are  liable  is  in  color 
and  consistence  between  the  two  kinds  mentioned  in  connection  with 
the  first  and  second  classes. 

The  author  is  acquainted  with  a  family,  consisting  of  seven  or  eight 
members,  most  of  whom  are  adults,  all  having  this  sort  of  teeth.  The 
most  thorough  attention  has  been  paid  by  each,  and  yet  all  have  lost 
most  of  their  teeth.  They  are  usually  first  attacked  in  their  approxi- 
mal  surfaces  and  indentations,  but  neither  their  labial  faces  nor  most 
prominent  points  are  exempt  from  caries.  No  sooner  is  its  progress 
•arrested  in  one  place  or  part  than  it  appears  in  another.  The  author 
has  had  occasion  to  fill  a  single  tooth  in  as  many  as  four,  five,  and 
even  six  different  places  ;  and  in  this  way,  though  his  efforts  at  the 
preservation  of  any  considerable  number  have  proved  unavailing,  he 
has  been  able  to  save  some  of  them.  But  it  is  not  necessary  to  particu- 
larize cases.     Every  dentist  has  seen  teeth  of  this  description. 

The  corrosive  properties  of  the  fluids  of  the  mouth,  however,  are 
sometimes  so  changed  by  an  amelioration  of  the  constitution  that,  not- 
withstanding the  great  susceptibility  of  the  teeth  to  disease,  they  are 
sometimes  preserved  to  a  late  period  of  life,  or  until  the  general  health 
relapses  into  its  former  or  some  other  unfavorable  condition.  This 
has  happened  in  several  instances  that  have  come  under  the  author's 
immediate  observation,  and  it  should  be  borne  in  mind  that  the  sol- 
vent qvialities  of  these  juices  are  influenced  by  the  state  of  the  consti- 
tutional health. 

Class  Fourth. — Teeth  of  this  class  usually  have  a  white,  chalky 
appearance,  are  unequally  developed,  and  of  a  very  soft  texture. 
They  are  easily  acted  upon  by  corrosive  agents,  and,  like  the  teeth  last 
noticed,  generally  fall  speedy  victims  to  disease,  unless  great  care  is 
taken  to  secure  their  preservation. 

Persons  who  have  teeth  such  as  described  in  this  class,  generally 
have  what  Laforgue  calls  lymphatico-serous  temperaments.  Their 
blood  is  usually  pale,  the  fluids  of  the  mouth  abundant,  and  for  the 
most  part  exceedingly  viscid.  They  do  not  have  that  white,  frothy 
appearance  observable  in  healthy,  sanguineous  individuals. 

As  teeth  that  are  neither  too  large  nor  too  small,  and  that  have  a 
close,  compact  texture,  and  tinged  with  yellow,  are  indicative  of  an 
originally  good  constitution,  whatever  it  may  be  at  the  present  time, 
so  those  that  are  long,  narrow,  and  faintly  tinged  with  blue,  as  well  as 
those  that  greatly  exceed  the  ordinary  size,  and  that  are  irregular  in 


CHAEACTERISTICS   OF   THE   TEETH.  181 

shape,  and  have  a  rough,  muddy  appearance,  furnish  assurance  of  a 
constitution  originally  bad.  The  first  of  the  latter  descriptions  of 
teeth  are  more  frequently  met  with  among  females  than  males,  and 
among  those  of  strumous  habit,  than  those  in  whom  this  diathesis  does 
not  exist. 

Class  Fifth. — The  teeth  belonging  to  this  class  are  characterized  by 
whiteness  and  a  pearly  gloss  of  the  enamel.  They  are  long  and  usually 
small  in  circumference,  though  sometimes  well  developed.  They  are 
regarded  by  many  as  denoting  a  tendency  to  phthisis  pulraonalis,  and 
are  supposed  by  some  to  be  very  durable  ;  but  the  author  has  observed 
that  individuals  who  have  this  sort  of  teeth,  when  attacked  by  febrile 
or  any  other  form  of  disease  having  a  tendency  to  alter  the  fluids  of 
the  body,  are  very  subject  to  toothache  and  caries  ;  and  that  Avhen  this 
condition  of  the  general  system  is  continued  for  a  considerable  length 
of  time,  the  teeth,  one  after  another,  in  rapid  succession,  crumble  to 
pieces. 

It  would  seem,  from  this  circumstance,  that  the' fluids  of  the  mouth 
in  subjects  of  strumous  habit,  if  free  from  other  morbid  tendencies,  are 
less  prejudicial  to  the  teeth  than  they  are  in  most  other  constitutions, 
and  the  author  is  of  the  opinion  that  it  is  owing  to  this  that  they  are 
so  seldom  attacked  by  caries. 

M.  Delabarre,  in  speaking  of  persons  who  have  teeth  which,  though 
beautiful,  from  having  smooth  and  apparently  polished  surfaces,  pre- 
sent shades  intermixed  with  a  dirty  white,  says,  they  "have  had 
alternations  of  good  and  indifferent  health  dui'ing  the  formation  of 
the  enamel.  These  teeth,"  he  continues,  "  ordinarily  have  elongated 
crowns,  and  many  present  marks  of  congenital  atrophy."  Again  he 
observes,  "  Teeth  of  this  sort  deceive  us  by  appearing  more  solid  than 
they  are;  they  remain  sound  until  about  the  age  of  fourteen  or 
eighteen  ;  at  this  period  *a  certain  number  of  them  decay,  especially 
when  in  infancy  the  subject  was  lymphatic,  and  continued  to  be  so  in 
adolescence.  This  description  of  teeth  is  frequently  met  with  among 
the  richer  classes,  in  which  children  born  feeble  reach  puberty  only  by 
means  of  great  care,  and,  consequently,  owe  their  existence  solely  to 
the  unremitting  attention  of  their  parents  and  the  strengthening  regi- 
men that  the  physician  has  caused  them  constantly  to  pursue.  Hav- 
ing reached  the  eighteenth  or  twentieth  year,  their  health  is  confirmed, 
but  the  mucous  membranes  ever  after  have  a  tendency  to  be  affected  ; 
the  redder  color  of  the  mouth,  more  especially  its  interior  part,  and 
that  of  the  lips,  and  the  upper  part  of  the  palate,  which,  by  degrees, 
discovers  itself  as  the  subject  gradually  advances  in  years,  showing  an 
ameliorated  condition.  It  is  thus  that  numerous  persons,  having 
gained  a  sanguineous  temperament,  would  deceive  us,  if  it  were  not 


182  DENTAL  PATHOLOGY,  THERAPEUTICS. 

that  some  marks  of  erosion  are  seen  on  the  masticating  surfaces  of  the 
first  permanent  molars,  which  informs  us  that  the  present  health  is  the 
result  of  amelioration," 

There  are  other  cases  in  which  the  teeth  are  of  so  inferior  a  quality 
that  they  no  sooner  emerge  from  the  gums  than  they  are  attacked  and 
destroyed  by  caries,  while  the  subjects  who  possess  them  are  enabled, 
by  skillful  treatment,  to  overcome  the  morbid  constitutional  tendencies 
against  which,  during  the  earlier  years  of  their  existence,  they  had  to 
contend,  and  eventually  to  acquire  excellent  health.  But  in  forming 
a  prognosis,  it  is  essential  to  ascertain  whether  the  general  organic 
derangement  which  prevented  the  teeth  from  being  well  formed,  and 
thus  gave  rise  to  their  premature  decay,  is  hereditary,  or  whether  it 
has  been  produced  by  some  accidental  cause  subsequent  to  birth.  The 
procurement  of  health  in  the  former  case  will  be  less  certain  than  in 
the  latter,  for  when  the  original  elements  of  the  organism  are  bad,  the 
attainment  of  a  good  constitution  is  more  difficult. 

Persons  of  sanguineo-raucous  temperaments,  having  suffered  in  early 
childhood  from  febrile  or  inflammatory  diseases,  often  have  their  teeth 
affected  with  what  Duval  calls  the  decorticating  process  (denudation 
of  their  enamel),  resulting,  no  doubt,  from  the  destruction  of  the  bond 
of  union  between  it  and  the  dentine. 

There  are  other  characteristics  which  the  teeth  present  in  shape, 
size,  density,  and  color,  and  from  which  valuable  inductions  might  be 
made,  both  with  regard  to  the  iunate  constitution  and  the  means 
necessary  to  their  own  preservation  ;  but  as  the  limits  assigned  to  this 
part  of  our  subject  will  not  admit  of  their  consideration,  we  shall  con- 
clude by  observing  that  the  appearances  of  these  organs  vary  almost 
to  infinity.  Each  is  indicative  of  the  state  of  the  general  health  at 
the  time  of  their  formation,  and  of  their  own  physical  condition  and 
susceptibility  to  disease. 


CHAPTER  III. 

DISEASES   OF   MUCOUS   MEMBRANE. 
STOMATITIS. 


THE  diseases  of  the  mucous  membrane  lining  the  mouth,  very 
common  at  the  periods  for  the  eruption  of  the  teeth  and  later  in 
life,  are  comparatively  rare  during  foetal  life,  and  differ,  as  regards 
symptoms,  in  accordance  with  the  nature  of  the  affection  and  the  part 
of  the  mucous  surface  in  which  it  may  have  its  origin. 


DISEASES   OF   MUCOUS   MEMBRANE.  183 

The  most  common  affection  of  the  membrane  lining  the  mouth  is 
known  by  the  general  term  stomatitis,  from  tlie  Greek  word  (xro/j.a, 
"mouth,"  and  itis,  "a  suffix  denoting  inflammation,"  and  is  described 
by  Prof.  Wood  as  follows : — 

"  Inflammation  of  the  mouth  appears  in  reddened,  somewhat  elevated 
patches,  or  occupies  large  portions  of  the  surface,  sometimes  extending 
apparently  over  the  whole  mouth.  In  some  cases  it  is  superficial, 
with  little  or  no  swelling,  and  may  be  designated  as  erythematous, 
from  the  Greek  word  spui^po<i,  'red;'  in  others  it  occupies  the  whole 
thickness  of  the  membrane,  extending  sometimes  to  the  submucous 
tissue,  and  even  to  the  neighboring  structures,  as  the  sublingual  and 
submaxillary  glands,  and  the  absorbent  glands  of  the  neck,  and  occa- 
sions considerable  tumefaction  in  all  these  parts.  In  the  erythematous 
form  it  is  characterized  by  redness  and  sense  of  heat,  and  sometimes 
considerable  tenderness,  but  is  not  usually  attended  with  acute  pain  ; 
when  deeper  in  the  tissue  it  is  often  very  painful. 

"Portions  of  the  epithelium  sometimes  become  opaque,  giving  an 
appearance  of  whiteness  in  streaks  or  patches.  Occasionally  this 
coating  is  elevated  in  blisters,  or  even  detached,  like  the  cuticle,  from 
the  skin,  in  scales.  Superficial  ulcerations  not  unfrequently  occur, 
which  may  spread  over  considerable  portions  of  the  membrane.  In 
certain  states  of  the  constitution  the  ulcerative  tendency  is  very  strong 
and  deep,  and  extensive  sores  occur,  which  are  sometimes  attended 
with  gangrene. 

"  There  is  often  a  copious  flow  of  saliva ;  though,  in  some  instances, 
this  secretion,  as  well  as  that  of  the  mucous  follicles,  is  checked,  and 
the  mouth  is  clammy  or  dry.  The  sense  of  taste  is  usually  more  or 
less  impaired,  and  speech  and  mastication  are  often  difficult  and  painful. 
When  the  tongue  is  affected,  its  surface  is,  in  general,  first  covered 
with  a  whitish  fur,  through  which  the  red  and  swollen  follicles  may 
often  be  seen  projecting.  This  fur  sometimes  breaks  off,  leaving 
the  surface  red,  smooth  and  glossy,  with  here  and  there  prominent 
follicles ;  or  the  surface  may  be  hard,  dry,  or  gashed  with  painful 
fissures.  When  the  gums  are  involved,  they  swell,  and  rise  up  between 
the  teeth,  around  the  necks  of  which  they  frequently  ulcerate.  In 
some  cases  this  ulceration  does  not  cease  until  it  has  extended  into  the 
sockets,  and  destroyed  altogether  the  connections  of  the  teeth,  which 
become  loosened  and  fall  out,  after  which  the  gums  will  heal. 

"  Ordinary  inflammation  of  the  mouth  is  seldom  so  violent  as  to 
induce  symptomatic  fever.  This  form  of  inflammation  is  more  fre- 
quently a  complication  of  other  diseases  than  an  original  affection. 
When  of  the  latter  character,  it  is  generally  caused  by  the  direct 
action  of  irritant  bodies,  as  by  scalding  drinks,  acrid  or  corrosive  sub- 


184  DENTAL  PATHOLOGY,  THERAPEUTICS. 

stances  taken  into  the  mouth,  or  unhealthy  secretions  from  decayed 
teeth.  The  sharp  edge  of  a  broken  tooth  sometimes  gives  rise  to  much 
inflammation,  and  even  deep  and  obstinate  ulcers,  es23ecially  of  the 
tongue.  Inflammation  of  the  mouth  may  also  result  from  the  reaction 
which  follows  the  long  contact  of  very  cold  substances,  such  as  ice, 
with  the  interior  of  the  mouth.  It  sometimes  proceeds  from  the  propa- 
gation of  inflammation  from  the  fauces,  and  is  a  frequent  consequence 
of  gastric  irritation  produced  by  sour  or  acrid  matter  in  the  stomach. 
Drunkards  seem  peculiarly  predisposed  to  it.  Of  the  constitutional 
causes  none  are  so  frequent  as  the  state  of  fever,  which,  whatever  may 
be  its  peculiar  character  is  very  apt  to  afi^ect  the  mouth,  and  not  unfre- 
quently  occasions  inflammation." 

Simple  or  Catarrhal  Stomatitis. — This  is  a  form  of  stomatitis  common 
■to  children  under  the  age  of  one  year.  While  giving  rise  in  itself  to 
no  severe  symptoms,  yet  it  may  be  connected  with  other  serious  mala- 
dies, and  hence  is  often  overlooked.  While  it  is  more  intense  in  one 
part  than  in  another,  it  may  be  confined  to  the  tongue  alone,  or  be 
universally  diffused  over  the  whole  mucous  membrane  of  the  mouth. 
It  is  characterized  by  an  increase  of  the  heat  and  redness  of  the  part 
aflfected,  more  or  less  thickening  of  the  inflamed  mucous  membrane, 
rapid  proliferation  and  exfoliation  of  epithelial  cells,  and  more  or  less 
dryness  of  the  surface,  with  a  high  degree  of  sensibility,  and  pain  when 
the  lips  or  tongue  are  moved.  In  severe  cases  the  gums  become 
swollen  and  spongy,  and  bleed  readily,  and  the  tongue  is  covered  with 
a  light  fur ;  there  is  an  increased  flow  of  saliva,  which  may  dribble 
from  the  corners  of  the  mouth.  Among  the  early  symptoms  are  rest- 
lessness and  fretfulness,  with  refusal  to  take  food,  or  when  attempting 
to  do  so,  suddenly  ceasing,  on  account  of  the  pain  experienced. 

The  intensity  of  this  affection  varies  in  diflTerent  cases,  sometimes 
existing  in  such  a  slight  form  as  to  cause  little  uneasiness,  and  quietly 
disappearing,  while  at  other  times  it  may  cause  intense  pain,  and  con- 
tinue for  weeks  or  months. 

In  a  severe  form  it  may  extend  to  the  oesophagus  and  stomach,  or 
the  larynx  and  trachea,  and  at  last  prove  fatal,  especially  if  there  is 
present  a  decided  state  of  cachexia,  or  a  severe  co-existing  disease. 

When  it  occurs  during  the  period  of  dentition,  to  which  it  is  com- 
mon, it  is  often  accompanied  with  fever,  and  sometimes,  especially 
when  long  continued,  by  a  profuse  flow  of  saliva ;  occurring  previous 
to  dentition,  it  is  seldom  accompanied  with  fever. 

When  caused  by  dentition,  the  gum  over  the  erupting  tooth  becomes 
inflamed,  and  the  inflammation  may  extend  over  the  entire  buccal 
surface.  But  when  due  to  the  irritation  of  dentition,  this  form  of 
stomatitis  is  generally  more  circumscribed  than  when  it  arises  from  a 


DISEASES    OF    MUCOUS    MEMBRANE.  185 

constitutional  cause.  It  may  also  result  from  a  mercurial  course  of 
ti'eatment,  exposure  to  cold,  hot  and  stimulating  food,  or  a  diseased 
condition  of  the  alimentary  canal. 

In  very  young  children  it  may  result  from  violent  exertions  of  the 
tongue  and  lips  in  attempting  to  suck  from  an  over-distended  breast  or 
a  malformed  nipple. 

Simple  stomatitis  is  readily  relieved  by  means  of  emollient  washes, 
such  as  solutions  made  from  the  slippery  elm  bark  or  the  pith  of  sassa- 
fras, in  cold  water.  When  severe,  a  leech  or  two  applied  to  the 
angle  of  the  jaws  will  prove  serviceable,  and  as  a  wash,  the  acetate  of 
lead,  in  a  solution  composed  of  three  grains  to  one  fluidounce  of 
water.  A  few  doses  of  bi'omide  of  potassium  may  relieve  the  nervous 
excitement  and  fretfulness.  One  part  of  borax  to  three  of  honey,  or  a 
drachm  of  borax  to  an  ounce  of  glycerin  and  water,  or  a  weak  solu- 
tion of  alum,  may  prove  useful  local  remedies. 

When  the  inflammation  of  the  mouth  is  symptomatic  of  a  diseased 
condition  of  the  alimentary  canal,  the  remedies  adapted  to  such  a  con- 
dition are  necessary. 

Ulcerous  Stomatitis  is  another  affection  of  the  mouth  which  is  com- 
mon to  childhood,  the  premonitory  symptoms  being  the  same  as  in 
simple  stomatitis.  The  inflammation  usually  begins  upon  the  gums 
and  extends  along  the  buccal  surface.  An  examination  of  the  mouth, 
however,  at  this  stage  of  the  disease,  reveals  one  or  more  small,  inflamed 
and  slightly  elevated  points  or  pimples,  which,  sometimes  within  a  few 
hours,  but  more  commonly  after  one  or  two  days,  present  a  softened 
and  yellowish  apex,  and  at  length  a  small  ulcer,  superficial  at  first,  but 
gradually  becoming  deeply  excavated,  with  often  an  inflamed  and  ele- 
vated margin.  The  surfaces  of  these  ulcers  are  covered  with  an  ash- 
colored  or  a  yellowish  matter,  in  the  majority  of  cases  ;  but  sometimes, 
instead  of  being  thus  covered,  their  surfaces  are  bare,  and  bleed  readily. 

Some  of  the  ulcers  may  unite  and  form  large,  irregular  ulcerations, 
while  others  remain  isolated.  The  ulceration,  when  severe,  gives  rise 
to  considerable  swelling,  especially  around  the  ulcers,  and  the  swollen 
part  is  soft,  and  not  very  tender  on  pressure.  The  soft,  yielding  na- 
ture of  the  swelling  enables  this  form  to  be  distinguished  from  gan- 
grenous ulceration,  as  there  is  more  induration  in  the  latter  affection. 
These  ulcers  result  from  acute  phlegmonous  inflammation,  and  may 
attack  any  part  of  the  raucous  membrane  lining  the  mouth,  but  are 
most  commonly  found  on  the  sides  of  the  frsenum,  along  the  inferior 
margin  and  edges  of  the  tongue,  and  inside  the  lips. 

It  is  but  seldom  that  they  are  found  on  the  ui3per  surface  of  the 
tongue  ;  but  when  they  do  appear  on  this  surface,  they  are  generally 
superficial,  and  not  deeply  excavated. 


186  DENTAL  PATHOLOGY,  THERAPEUTICS. 

When  the  ulcers  in  this  form  of  stomatitis  are  fully  formed,  there 
is  usually  a  profuse  flow  of  saliva,  and  a  decrease  of  the  febrile  ex- 
citement. The  bowels,  which  in  the  first  stage  of  the  disease  are 
costive,  now  become  loose,  and  often  very  much  so  during  its  con- 
tinuance. A  simple  form  of  ulcerous  stomatitis  is  characterized  by 
but  one  or  two  small  ulcers,  which  in  a  little  time  fill  up  with  granu- 
lations and  soon  heal  over.  In  a  more  severe  form  of  this  disease  a 
considerable  number  of  these  ulcers  exist,  in  some  cases  covering 
almost  the  whole  of  the  mucous  membrane  of  the  gums,  the  inside  of 
the  cheeks,  arch  of  the  palate,  sides  and  inferior  surface  of  the  tongue. 

Another  form  of  this  disease  is  sometimes  met  with,  where  but  one  or 
two  ulcers  exist,  but  which  gradually  extend  over  the  mucous  surface, 
at  the  same  time  increasing  in  depth,  and  with  no  appearance  of  heal- 
ing. This  form  of  the  aflfection  is  attended  with  hectic  fever,  the  ex- 
acerbations occurring  night  and  morning,  and  rapidly  wearing  away 
the  strength. 

There  is  yet  another  form  of  ulcerous  stomatitis  occasionally  met 
with,  which  consists  of  a  softening  of  the  mucous  membrane  of  the 
palate  in  its  centre,  either  on  the  median  line  or  outside  this  line.  The 
membrane  appears  to  be  softened  into  a  kind  of  pulp,  of  a  red  or  fawn 
color,  which,  on  its  removal,  discloses  an  ulcer  with  perpendicular 
walls ;  the  bone,  however,  forming  its  base,  is  found  to  be  perfectly 
healthy.  It  is  the  opinion  of  some  that  ulcerous  stomatitis  is  con- 
tagious ;  that  is,  that  it  may  be  communicated  by  using  the  same  spoon 
in  eating,  and  also  that  it  is  endemic  and  epidemic.  Ulcerous  stoma- 
titis is  common  to  the  period  of  dentition,  especially  when  there  is  dis- 
order of  the  digestive  organs. 

The  causes  of  ulcerous  stomatitis  are  uncleanliness,  poor  food,  resi- 
dence in  damp,  dirty  places,  mercury,  a  cachectic  condition,  enfeebled 
system,  and  contagion. 

The  treatment  of  ulcerous  stomatitis  consists  in  a  change  of  resi- 
dence and  diet,  cleanliness,  the  use  of  tonics,  ferruginous  or  vegetable, 
such  as  the  liquor  ferri  nitratis,  with  tincture  of  calumba,  given  in 
simple  syrup,  and  such  local  remedies  as  nitrate  of  silver  or  muriatic 
acid,  with  an  alternate  wash  of  honey  and  borax,  equal  parts ;  or  the 
chloride  of  lime  applied  dry  to  the  ulcerated  surface  twice  daily,  and 
simple  water  used  during  the  interval,  and  continued  until  a  healthy 
appearance  is  apparent,  when  a  weak  solution  of  chloride  of  lime,  one 
grain  to  forty-five  of  water,  is  employed.  Chloride  of  lime  one  drachm, 
with  honey  one  ounce,  is  also  recommended.  Chlorate  of  potassium 
often  acts  like  a  specific,  employed  internally  and  externally,  the  dose 
of  which  is  two  or  three  grains,  dissolved  in  water  with  sugar,  or  in 
syrup. 


DISEASES   OF   MUCOUS   MEMBRANE.  187 

The  following  formula  maj^  be  employed : — 

R.     Potass,  chlorat ,^sstoj 

Mellis 5  ss 

Aquee ^ij.     M. 

One  teaspoonful  every  two  hours,  and  the  same  applied  as  a  lotion. 

Dr.  Coiidie  recommends  the  following  treatment  where  the  ulcers  are 
slow  in  healing  : — A  solution  of  borax,  gr.  xv  to  the  ounce  of  water, 
or  a  weak  solution  of  the  nitrate  of  silver,  gr.  j  to  the  ounce  of  water, 
or  sulphate  of  copper,  gr.  v  to  the  ounce  of  water,  or  acidura  nitrieum 
dilutum  applied  by  means  of  a  camel's  hair  pencil  to  the  whole  of  the 
ulcerated  surface,  which,  will  improve  the  character  of  the  ulceration 
and  arrest  its  progress. 

"  Any  apparent  cause  of  irritation,  such  as  a  decayed  tooth,  should 
be  removed."  When  there  is  great  derangement  of  the  alimentary 
canal  accompanying  ulcerous  stomatitis,  or  this  disease  occurs  during 
the  course  of  other  acute  and  chronic  diseases,  such  as  pneumonia,  scar- 
let fever,  smallpox,  etc.,  the  proper  remedies  adapted  to  the  removal 
of  these  diseases  are  necessary. 

Aphthous  Stomatitis. — This  form  of  stomatitis,  sometimes  called 
"follicular  stomatitis,"  although  it  is  not  confined  to  the  seat  of  the 
follicles,  is  common  to  all  ages,  but  is  most  frequent  during  childhood. 
The  seat  of  the  aphthge  is  usually  the  inner  surfaces  of  the  lips  and 
cheeks,  the  gums,  the  tongue,  and  sometimes  the  roof  of  the  mouth. 
They  commence  with  a  vascular  injection,  which  is  followed  in  a  few 
hours  by  a  whitish  exudation  immediately  below  the  epithelium  and 
upon  the  corium,inthe  form  of  small,  round  or  oval,  isolated  spots,  the 
smallest  being  of  the  size  of  a  pin's  head,  but  the  greater  number  of  a 
diameter  of  one  or  two  lines,  causing  slight  projections  on  the  surface 
of  the  mucous  membrane.  After  a  few  days  the  exudation  softens, 
and  the  points  become  denuded  of  epithelium,  presenting  superficial, 
painful  ulcers,  but  without  indurated  edges.  After  an  existence  of  one 
or  two  weeks  the  aphthae  disappear,  leaving  red  spots,  which,  however, 
soon  fade.  Besides  being  very  painful  to  the  touch,  and  also  to  food 
and  liquids,  they  are  attended  with  an  increased  secretion  of  saliva. 

Two  or  more  of  the  ulcers  may  coalesce,  forming  one  large  ulcerated 
patch,  which,  in  rare  cases,  may  become  gangrenous,  when  the  aflfection 
is  usually  complicated  with  gastro-intestinal  disease.  The  constitu- 
tional symptoms  are  generally  slight,  except  when  there  is  a  tendency 
to  gangrene,  which  may  cause  a  feeble  pulse,  pallid  countenance,  wasted 
body  and  limbs,  and  great  prostration. 

The  causes  of  aphthous  stomatitis  may  be  bad  hygienic  conditions, 
uncleanliness  and  privation,  but  it  is  usually  owing  to  some  derange- 
ment of  the  digestive  organs,  when  it  may  also  be  accompanied  with 


188  DENTAL  PATHOLOGY,  THERAPEUTICS. 

diarrhoea.  It  differs  from  ulcerous  stomatitis  in  form  of  the  aphthse, 
and  the  inflammation  being  confined  to  the  immediate  vicinity  of  the 
ulcers,  and'  not  extending  over  the  mouth. 

The  treatment  of  aphthae  consists  in  the  application  of  demulcent 
drinks,  such  as  the  mucilage  of  gum  acacia,  flaxseed  or  marsh  mallow. 
Mel-boracis,  honey  of  borax,  is  an  efficient  application  applied  with  a 
camel's-hair  pencil,  and  a  small  quantity  of  some  opiate  to  relieve  the 
tenderness  of  the  ulcers,  and  the  restlessness.  When  the  ulcers,  besides 
being  painful,  are  not  disposed  to  heal,  they  may  be  touched  with 
nitrate  of  silver,  or  with  hydrochloric  acid  in  honey  of  roses.  When 
there  is  a  great  number  of  the  ulcers,  with  considerable  fever,  and 
symptoms  of  cerebral  congestion,  or  of  convulsions,  the  administra- 
tion of  laxatives,  and  the  bromides,  with  a  warm  foot  bath,  will 
prove  beneficial. 

Thrush. — This  affection,  also  known  as  "sprue"  and  "muguet,"  is 
characterized  by  a  form  of  inflammation  which  consists  of  points  and 
patches  of  a  curd-like  appearance  on  the  surface  of  the  mucous  mem- 
brane of  the  mouth,  its  common  seat,  as  the  fauces,  pharynx  and 
cesophagus  are  only  occasionally  aflTected. 

Thrush  commences  as  simple  inflammation  of  the  mucous  surface, 
which  is  followed  by  the  appearance  of  minute  semi-transparent  points 
or  granules,  which  soon  become  white  and  opaque.  While  some  re- 
main as  points,  others  extend,  and  by  coalescing  form  patches,  the  sur- 
faces of  which  are  not  uniform,  but  unequally  elevated. 

The  central  part  of  the  points  and  patches  project  but  little  above 
the  surrounding  epithelial  surface,  being  not  more  than  a  line  in  height. 
They  resemble  in  color  and  consistence  portions  of  curdled  milk,  for 
which  they  may  be  mistaken.  Being  very  easily  detached,  they  are 
rapidly  reproduced,  and  their  white  color  may  change  to  a  yellow  hue. 

Composed  of  epithelial  cells  and  a  parasitic  vegetable  growth,  of  the 
oidium  albicans  variety,  each  point  consists  of  roots,  branches  and 
sporules,  the  roots  being  transparent,  and  penetrating  the  epithelial 
layer,  and  sometimes  even  as  far  as  the  basement  membrane.  The 
branches  divide  and  subdivide,  and  consist  of  elongated  cells  with  one 
or  two  nuclei.  Around  the  branches  are  numerous  sporules.  Thrush, 
in  its  mildest  form,  appears  in  points  or  small  patches  ;  and  if  the 
patches  are  of  large  extent,  which,  however,  rarely  occurs,  the  affection 
is  attended  by  a  state  of  great  prostration  and  danger,  from  some  con- 
comitant disease.  Often  it  occurs  as  the  sequelae  of  pneumonia,  or 
gastro-intestinal  inflammation,  in  the  latter  case  being  caused  by  neglect, 
improper  food,  or  a  deprivation  of  the  maternal  milk.  In  the  mildest 
cases,  the  symptoms  are  similar  to  those  of  simple  stomatitis.  When  the 
inflammation  is  more  extensive,  and  especially  if  the  fauces  and  oesopha- 


DISEASES    OF    MUCOUS    MEMBRANE.  189 

gus  are  involved,  the  inflamed  surface  becomes  very  hot,  red,  and  pain- 
ful, and  there  is  fretfulness  and  fever.  In  the  severest  forms,  the  surface 
becomes  dry  and  parched,  the  inflammation  more  extensive,  and  there  is 
thirst,  loss  of  appetite,  vomiting,  and  frequently  diarrhoea,  with  an 
anxious,  pallid  countenance,  rapid  emaciation  and  extreme  prostration. 

The  causes  of  thrush  are  bad  hygienic  conditions,  constitutional 
feebleness,  indigestion  and  improper  food.  It  is  common  among 
children  in  crowded  institutions,  or  where  there  is  exposure  to  damp- 
ness. It  appears  to  be  more  prevalent  during  the  summer  months,  and 
to  occur  more  frequently  under  the  age  of  three  months. 

Even  children  of  eighteen  months,  suffering  from  debilitating  diseases, 
are  subject  to  it.  The  treatment  of  thrush  should  commence  with  an 
improvement  in  the  diet  and  locality,  if  these  are  at  fault,  and  the  ad- 
ministration of  an  alkali  to  correct  the  acidity  which  is  usually  present. 
Saccharate  of  lime  added  to  the  milk  is  very  beneficial.  The  local 
treatment  consists  in  the  application  of  borax  with  honey — mel-boracis, 
or  borax  with  powdered  sugar,  or  dissolved  in  water.  Some  object  to 
the  use  of  sugar,  as  it  promotes  the  growth  of  the  parasite.  Prof.  I.  L. 
Miller  recommends  the  following  : — 

R.     Sodii  borat 3j 

Glycerinse 3ij 

Aquse 3vj.     M. 

SiG. — To  be  applied  with  a  camel's  hair  pencil  four  or  five  times  a  day. 

If  such  an  ajDplication  fails,  which  is  rarely  the  case,  then  recourse 
must  be  had  to  a  solution  of  nitrate >of  silver,  or  sulphate  of  zinc. 

Be.     Zinci  sulph gr.  ij-iv 

Aquae  rosEe §ij.     M. 

When  thrush  is  complicated  with  other  diseases,  the  proper  treat- 
ment for  such  diseases  may  render  its  treatment  easy  and  effectual. 

Gangrene  of  the  Mouth. — This  disease,  characterized  by  such  names 
as  "  Cancrum  Oris,"  "  Gangraenopsis,"  "  Canker  of  the  Mouth," 
"  Water  Canker,"  is  common  to  children  of  debilitated  constitutions 
and  a  decided  lymphatic  temperament,  the  result  of  scanty  nourish- 
ment, improper  clothing,  and  damj),  unhealthy  places  of  abode,  or 
where  many  children  are  crowded  together,  in  charitable  institutions. 
There  are  several  forms  of  this  affection,  the  most  common,  perhaps, 
being  preceded  by  inflammation  of  the  gums,  with  such  premonitory 
symptoms  as  great  languor  and  listlessness,  indisposition  to  any  exei'- 
cise,  irritable  temper,  loss  of  sleep  and  appetite,  and  increase  of  thirst. 
The  countenance  becomes  pale  and  dejected,  and  a  peculiar  puckering 
of  the  cheeks  is  observed  about  the  corners  of  the  mouth.  Emaciation 
and  nig;ht  sweats  are  not  uncommon. 


190  DENTAL  PATHOLOGY,  THERAPEUTICS. 

These  premonitory  symptoms  may  continue  for  several  days,  or  even 
weeks,  when  an  acute  pain  is  felt  in  the  mouth  and  gums,  with  a  sense 
of  heat  and  itching  about  their  margins,  the  free  edges  of  which  become 
congested  and  thickened,  spongy,  and  of  a  dark  red  or  purple  hue, 
bleeding  readily. 

The  flow  of  saliva  increases  greatly,  and  is  frequently  mixed  with 
blood.  From  about  the  necks  of  the  teeth  a  muco-purulent  matter  is 
discharged,  which  after  a  time  becomes  thin,  watery  and  acrid,  ren- 
dering the  breath  very  offensive.  In  the  majority  of  cases  this  disease 
is  confined  to  one  side  of  the  mouth  and  to  the  lower  jaw,  and  if 
allowed  to  progress,  the  gums  separate  from  the  necks  of  the  teeth  and 
alveolar  processes,  and  become  ragged,  flabby,  and  livid  ;  the  teeth  on 
the  affected  side  loosen,  and  at  length  drop  out,  and  at  this  stage  there 
is  an  increase  of  the  febrile  symptoms  and  night  sweats.  In  such  a 
state  the  gums  may  continue  for  weeks  or  even  months,  but  usually 
after  a  few  days  a  number  of  ash-colored  vesicles  make  their  appear- 
ance, which  rapidly  increase  in  size  and  become  confluent,  the  divided 
gum  presenting  a  gangrenous  appearance.  The  dead  portions  separate, 
a  gangrenous  ulcer  follows,  and  soon  the  entire  part  is  destroyed,  and 
the  inferior  maxillary  bone  exposed.  The  ulceration  is  more  common 
to  the  labial  surface  than  to  the  lingual,  and  commences  in  the  front 
part  of  the  mouth,  extending  to  posterior  parts.  The  ulcers  before 
becoming  gangrenous  are  covered  with  a  yellow  or  gray  secretion, 
which,  on  being  removed,  exposes  many  small,  red  papillae,  which 
correspond  to  imperfect  granulations.  After  a  time  the  gangrenous 
ulceration  extends  to  the  mucous  membrane  of  the  cheek  and  lips, 
causing  pain  and  difficulty  in  attempting  to  open  the  mouth,  which  is 
sometimes  impossible. 

In  a  short  time  the  whole  of  the  mouth  becomes  affected,  and  death 
usually  occurs  at  about  the  eighth  or,  at  the  furthest,  upon  the  four- 
teenth day  from  the  commencement  of  the  gangrene. 

Mr.  Tomes  remarks,  that  although  the  disease  is  usually  confined 
to  children  during  the  shedding  of  the  temporary  teeth,  yet  adults  are 
not  wholly  exempt  from  its  attacks. 

There  is  another  form  of  this  disease  which  differs  considerably 
from  that  just  described,  from  the  fact  that  it  is  not  preceded  by 
inflammation  of  the  gums,  but  commences  in  the  cheek,  usually  at  the 
angle  of  the  lips,  and  comes  on  abruptly,  without  the  premonitory 
symptoms  characteristic  of  the  first  form  described. 

There  is  first  seen  a  hard,  indolent  tumor,  about  the  size  of  an 
almond,  in  some  part  of  the  lips  or  cheek,  which  is  deej)ly  seated,  the 
skin  covering  it  being  somewhat  redder  than  natural.  This  tumor 
gradually  increases  in  size  for  a  few  days,  when  the  mucous  membrane 


DISEASES    OF    MUCOUS    MEMBRANE.  191 

covering  it  presents  a  gangrenous  appearance,  with  an  offensive  odor. 
Before  this  occurs,  however,  the  external  redness  of  the  skin  covering 
the  tumor  becomes  pale,  then  livid,  then  of  a  grayish  hue,  surrounded 
by  a  red  circle,  which  spreads  rapidly,  and  in  a  few  hours  changes  to 
a  black  color. 

The  gums  nearest  to  this  tumor  then  become  gangrenous,  and  the 
teeth  loosen,  and  at  length  fall  out.  Death  usually  occurs  before  the 
death  of  the  bone  of  the  jaw.  There  is  also  a  superficial  form  of  gan- 
grene sometimes  met  with  in  the  form  of  spots  of  a  dark-brown  color 
surrounded  by  a  red  margin,  which  vary  in  size,  and  have  for  their 
seat  the  corners  of  the  lips  and  inner  surfaces  of  the  cheeks.  These 
spots  may  first  appear  in  the  form  of  slightly  reddened  patches,  but  in 
this  mild  form  are  always  superficial,  confined  to  the  mucous  mem- 
brane alone,  the  sloughs  separating  with  little  loss  of  substance,  soon 
to  be  followed  by  healthy  granulations  and  cicatrization. 

Gangrene  of  the  mouth  may  occur  at  any  period  between  the  first 
and  tenth  year  of  age,  but  is  more  common  between  the  second  and 
fourth  years;  and  the  children  subject  to  it  are  those  of  a  lymphatic 
temperament,  delicate  constitution,  soft,  flaccid  muscles,  pale  skin,  and 
whose  digestive  organs  are  deranged.  It  usually  occurs  in  those  whose 
systems  are  much  reduced  or  cachectic,  and  is  more  common  to  chil- 
dren crowded  together  in  asylums,  and  those  deprived  of  pure  air  and 
proper  nourishment,  or  enfeebled  by  disease.  It  sometimes  follows  the 
eruptive  fevers,  and  such  diseases  as  pneumonia,  scrofula,  whooping- 
cough,  typhus  fever,  ague,  etc. 

In  the  treatment  of  gangrene  of  the  mouth  no  little  depends  upon 
the  time  this  is  instituted.  Before  the  gangrene  makes  its  appearance 
much  may  be  dorie  in  the  way  of  preventive  treatment,  in  order  to 
remove  the  existing  predisposition.  A  dry,  pure  air,  cleanliness,  and 
a  nourishing  diet  adapted  to  the  condition  of  the  digestive  organs,  are 
very  essential.  The  preparations  of  iron  and  bitter  vegetable  tonics 
are  required. 

The  administration  of  the  sulphate  of  quinine,  and  the  local  applica- 
tion of  a  strong  decoction  of  white  oak  bark,  is  thought,  by  Dr.  Condie, 
to  be  beneficial  in  preventing  gangrene  of  the  mouth  in  cases  in  which 
there  is  every  reason  to  anticipate  its  speedy  occurrence.  A  solution 
of  sulphate  of  zinc  (one  drachm  to  the  ounce  of  W'ater),  to  which  is 
added  honey  and  tincture  of  myrrh,  two  drachms  of  each,  will  also 
prove  serviceable.  Nitrate  of  silver,  either  in  the  solid  form  or  in 
solution,  applied  to  the  affected  part,  has  been  successfully  employed  in 
a  large  number  of  cases. 

When  the  disease  is  established,  the  first  indication  in  the  local 
treatment  is  to  arrest  the  progress  of  the  gangrene,  and  hasten  the 


192  DENTAL  PATHOLOGY;  THERAPEUTICS. 

detachment  of  the  slough,  and  for  such  purposes  highly  stimulating  or 
escharotic  agents  are  required.  Such  applications  as  acetic,  sulphuric, 
nitric  and  hydrochloric  acids,  nitrate  of  silver,  acid  nitrate  of  mercury, 
chloride  of  antimony,  have  been  successfully  applied,  by  means  of  a 
brush,  on  and  about  the  slough,  to  be  at  once  followed  by  the  application 
of  dry  chloride  of  lime,  when  the  mouth  is  to  be  thoroughly  washed  out 
with  water,  by  means  of  a  syringe. 

After  the  separation  of  the  slough  the  escharotic  is  to  be  discontinued, 
and  the  chloride  of  lime  alone  employed.  Some,  however,  prefer 
milder  remedies  than  the  strong  acids,  such  as  nitrate  of  silver,  if  the 
slough  is  small  in  extent ;  if  larger,  muriated  tincture  of  iron  is  applied, 
undiluted,  and  after  the  progress  of  the  gangrene  is  arrested,  the  use  of 
astringent  stimulants,  such  as  tincture  of  myrrh  or  the  French  aromatic 
.wine. 

Dr.  Coates  found  sulphate  of  copper,  according  to  >the  following 
formula,  to  be  successful : — 

R.     Cupri  sulph Zn 

Pulv.  cinchonfE 5ss 

Aqua; liv.     M. 

To  be  applied  twice  a  day  to  the  entire  ulcerations  and  excoriations. 

In  milder  cases  a  solution  of  sulphate  of  zinc,  .^j  to  an  ounce  of 
water,  by  itself  or  combined  with  tincture  of  myrrh,  is  found  to  be 
useful.  If  the  milder  agents,  after  two  or  three  days'  use,  do  not  pre- 
vent the  gangrene  from  spreading,  strong  hydrochloric  acid,  applied  by 
a  camel's  h&,ir  pencil,  may  prove  efficacious,  and  its  use  immediately 
folowed  by  lime  water  made  turbid  by  lime.  To  correct  the  fetor, 
chlorine  or  carbolic  acid,  properly  diluted,  may  be  employed  alternately 
with  the  sulphate  of  copper,  or  Labarraque's  solution  of  chlorinated 
soda,  one  part  to  eight  or  ten  parts  of  water.  The  tincture  of  myrrh, 
with  tonics  and  a  nutritious  diet,  should  complete  the  treatment. 

Dr.  Condie  recommends  the  administration  of  sulphate  of  quinine 
during  the  time  the  local  remedies  are  being  applied,  as  follows  :— 

R.     Quinise  sulphat gr-  x 

■'Acid  sulph.  dil Til  x 

Sacch.  alb ^iv 

Aq.  cinnamon 5^^*     •'^• 

Dose  :  A  teaspoonful  every  three  hours. 

The  free  internal  use  of  the  chlorate  of  potassa,  one  to  three  scruples 
in  twelve  hours,  according  to  the  age  of  the  child,  has  been  employed 
with  advantage. 

For  the  diarrhoea  accompanying  the  disease,  and  especially  when  it 
is  proftise,  Dr.  Condie  recommends  acetate  of  lead,  as  follows: — 


DISEASES   OF    MUCOUS   MEMBRANE.  193 

R.     Acetat.  plurabi gr.  xvj 

Cretae  prep 9  iiss 

IpecacuanliEe gr.  iv 

Opii  pulv gi'- ij-     M- 

To  be  divided  in  xvj  portions  ;  one  to  be  given  every  three  or  four  hours. 

Mercurial  Stomatitis. — The  employment  of  mercury  as  a  medicinal 
agent  causes  increased  watery  evacuations,  increased  flow  of  bile  and 
saliva,  and,  as  a  consequence,  increases  the  flow  of  blood  to  the  secret- 
ing part.  But  when  administered  in  excess  other  effects  follow.  It  is 
capable  of  producing  inflammation,  especially  the  acute,  phlegmonous, 
adhesive  variety.  The  effects  of  its  use  depend  upon  the  quantity 
administered  and  the  susceptibility  of  the  patient  to  its  action.  When 
carried  to  excess,  the  mucous  membrane  of  the  mouth  becomes  tender, 
red,  and  swollen,  the  glands  beneath  the  jaw  become  painful,  and  at 
length  ulceration  occurs,  which  spreads  from  the  gums — where  the 
effects  of  the  drug  are  first  observed — to  fauces  and  throat,  and,  in 
extreme  cases,  the  parts  affected  may  perish. 

Prof.  Wood  describes  this  disease  as  follows :  "  Among  the  first 
indications  of  the  action  of  mercury  are  often  a  metallic  taste  in  the 
mouth,  like  that  of  brass  or  copper,  and  some  increase  of  saliva.  At 
the  same  time  a  close  examination  will  detect  a  slight  redness  and 
swelling  of  the  gums,  particularly  about  the  necks  of  the  lower  inci- 
sors, while  somewhat  below  their  edge  a  broad,  white  line  may  be 
observed,  depending  on  opacity  of  the  epithelium. 

"  The  patient  soon  begins  to  feel  some  uneasiness,  complaining  of 
soreness  when  the  gums  are  pressed,  and  of  pain  when  the  teeth  are 
forcibly  closed  together.  There  is  also  a  sense  of  stiffness  about  the 
jaws  when  the  mouth  is  opened,  and  they  feel  as  if  projecting  above 
their  proper  level.  The  flow  of  saliva  increases,  the  inflammation 
extends,  the  gums  and  palate  become  obviously  swollen,  and  the  tongue 
covers  itself  with  a  yellowish-white  or  brownish  fur,  and  is  often  so 
much  enlarged  as  to  exhibit  the  impression  of  the  teeth  upon  being 
projected  from  the  mouth.  The  throat  frequently  becomes  sore,  and 
the  cheeks  and  salivary  and  absorbent  glands  swollen  and  painful. 
There  is  often  severe  toothache  or  pain  in  the  jaws.  A  whitish  exuda- 
tion along  the  edges  of  the  gums  is  very  common. 

"  The  breath,  which  sometimes  from  the  beginning,  and  sometimes 
even  before  the  appearance  of  any  one  of  the  symptoms  mentioned, 
has  a  peculiar,  disagreeable  odor,  now  becomes  extremely  offensive,  and 
in  bad  cases, almost  intolerable.  Ulceration  often  occurs,  especially 
about  the  necks  of  the  teeth,  which  are  consequently  loosened,  and  in 
the  cheeks,  lips  and  fauces.  The  ulcers  often  have  their  origin  in  a 
vesicular  eruption.     The  whole  mouth,  with  its  appendages,  is  some- 

13 


194  DENTAL  PATHOLOGY,  THERAPEUTICS. 

times  so  swollen  that  it  can  scarcely  be  opened,  and  the  tongue  so 
much  enlarged  as  to  project  beyond  the  lips. 

"  The  patient  is  now  nearly  or  quite  unable  to  articulate  or  to  masti- 
cate his  food,  and  sometimes  can  scarcely  swallow.  Hemorrhage  is 
not  an  unfrequent  attendant  upon  the  bad  cases,  and  is  sometimes  so 
profuse  as  to  be  alarming.  Sloughing  also  takes  place,  and  portions 
of  the  jaw  bone  are  occasionally  laid  bare.  There  is  always  in  the 
severe  cases  more  or  less  fever,  which  is  partly  symptomatic  of  the 
local  affection  and  partly  the  direct  effect  of  the  mercury.  Death, 
from  the  exhausting  influence  of  the  irritation,  want  of  nourishment, 
and  hemorrhage,  has  occurred  in  numerous  instances,  but  the  patient 
usually  recovers  from  the  worst  forms  of  the  affection,  though  sometimes 
with  a  deformed  mouth. 

"  The  tongue  and  cheeks  have  occasionally  adhered  at  points  where 
their  ulcerated  surfaces  were  in  contact,  and  a  surgical  operation  has 
been  necessary  to  remove  the  evil." 

For  the  treatment  of  mercurial  stomatitis,  see  "  Treatment  of 
Mercurial  Inflammation  of  the  Gums." 

Scurvy-Scorbutus  is  a  disease  characterized  by  spongy  gums,  offen- 
sive breath,  livid  spots  on  the  skin,  great  general  debility,  and  a  pale, 
bloated  countenance. 

"  Scurvy,"  remarks  Prof  Wood,  "  is  generally  very  gradual  in 
its  approach,  so  that  it  is  scarcely  possible  to  say,  in  any  particular 
case,  what  was  its  precise  time  of  attack.  Attention  is  commonly  first 
attracted  by  an  unhealthy  paleness  of  complexion,  a  feeling,  on  the 
part  of  the  patient,  of  languor  and  despondency,  with  an  indisposition 
to  bodily  action,  and  unusual  fatigue  after  exercise ;  a  sensation  of 
weariness  and  aching  in  the  limbs,  as  from  over-exertion,  though  the 
patient  may  have  been  at  rest ;  and  some  swelling,  redness,  and  tender- 
ness of  the  gums,  with  a  tendency  to  bleed  from  slight  causes.  With 
the  advance  of  the  disease,  the  face  becomes  paler,  and  assumes  a 
somewhat  sallow  or  dusky  hue,  and  often  a  degree  of  puffiness  ;  the 
lips  and  tongue  become  pallid,  and  contrast  strikingly  with  the  gums, 
which  are  purple  or  livid,  especially  at  their  edges,  rise  up  between 
and  around  the  teeth,  are  soft  and  spongy,  and  bleed  from  the  slightest 
touch  ;  the  breath  is  offensive;  purplish  spots  or  blotches  appear  upon 
various  parts  of  the  surface,  beginning  usually  upon  the  lower  extremi- 
ties, and  afterward  extending  to  the  trunk,  arms,  and  neck,  though 
seldom  affecting  the  face ;  hemorrhage  frequently  occurs,  most  com- 
monly from  the  nose,  gums,  and  mouth,  but  sometimes  from  the 
stomach,  bowels  and  urinary  passages ;  the  feet  become  oedematous 
and  the  legs  swollen  and  painful ;  the  general  debility  increases,  and 
muscular  exertion  is  apt  to  be  attended  with  palpitation  of  the  heart, 


DISEASES   OF   JIUCODS   MEMBRANE.  195 

panting,  vertigo,  dizziness,  and  a  feeling  of  faintness.  The  petechial 
spots  are  evidently  owing  to  the  extravasation  of  blood  within  the 
cutaneous  tissue.  Occasionally  portions  of  the  surface  look  as  if 
bruised  without  having  suffered  any  violence;  and  blows,  which, 
under  ordinary  circumstances,  would  produce  no  effect,  now  give  rise 
to  extensive  ecchymosis.  Should  the  disease  continue,  all  the  symp- 
toms become  aggravated  ;  the  complexion  assumes  often,  with  its  pale- 
ness, a  livid  or  leaden  hue ;  the  gums  swell  greatly,  and  put  forth  a 
blackish,  fungous  growth,  so  as  sometimes  to  conceal  the  teeth  ;  blood 
continually  oozes  from  them ;  sloughing  occasionally  takes  place, 
laying  bare  the  necks  of  the  teeth,  and  extending,  in  very  bad  cases, 
even  to  the  cheek. 

"  The  teeth  become  loose  and  sometimes  fall  out ;  the  patient  is  un- 
able to  chew  solid  food,  in  consequence  of  the  state  of  his  gums.  The 
breath  becomes  intolerably  offensive  ;  hard  and  painful  tumefactions 
occur  in  the  calves  of  the  leg,  among  the  muscles  of  the  thigh,  upon 
the  tibiae  and  lower  jaw,  and  in  the  hand,  with  stiffness  and  contrac- 
tion of  the  joints,  especially  the  knee,  and  severe  pain  in  the  extremi- 
ties upon  every  attempt  at  movement ;  and  the  debility,  before  so 
prominent  a  feature  in  the  case,  now  becomes  excessive,  so  that  the 
least  exertion  is  dangerous,  and  the  patient  sometimes  dies  suddenly 
upon  rising  from  bed,  or  upon  being  conveyed,  without  great  caution, 
from  one  place  to  another.  Wounds,  even  slight  scratches,  degenerate 
into  unhealthy  ulcers ;  old  cicatrices  break  out  afresh,  and  existing 
ulcers  assume  a  new  and  much  worse  aspect.  The  bones  are  said  to 
be  softened,  united  fractures  are  again  opened,  and  in  the  young  the 
epiphyses  separate  sometimes  from  the  shaft. 

"  Throughout  the  complaint  the  tongue  is  usually  clean  and  moist ; 
and  the  appetite  and  digestion  remain  unimpaired  almost  to  the  last, 
unless  the  disease,  as  sometimes  liappens,  should  be  complicated  with 
fever.  Indeed,  there  is  often  a  craving  for  food,  especially  for  fresh 
vegetables  and  fruits  ;  occasionally,  however,  there  is  vomiting,  with 
epigastric  distress,  and  other  evidences  of  stomachic  disorder.  The 
bowels  are  mostly  costive,  and  in  some  cases  obstinately  so,  but  diar- 
rhoea not  unfrequeutly  intervenes,  with  black  or  bloody  and  offensive 
evacuations.  The  pulse  is  generally  small,  feeble,  and  slow  ;  but  cases 
occur  in  which  it  becomes  very  frequent,  and  the  surface  of  the  skin 
febrile,  probably  from  the  sympathy  of  the  system  with  various  local 
irritative  congestions. 

"  Great  emaciation  usually  attends-the  disease  when  severe  or  lasting, 
but  not  invariably.  Little  cerebral  disturbance  is  ordinarily  observ- 
able, and  the  patient  often  retains  full  possession  of  his  senses  and  intel- 
lect to  the  last." 


196  DENTAL  PATHOLOGY,  THERAPEUTICS. 

In  regard  to  the  cause  of  scurvy,  it  is  the  general  belief  that  it 
results  from  the  absence  of  fresh  vegetables  and  fruits.  Prof.  Hamil- 
ton says,  "  In  regard  to  the  pathology  of  scurvy,  the  belief  prevails 
that  it  is  due  essentially  to  the  absence  of  certain  starai.nal  principles 
from  the  blood,  and  es^^ecially  potash;  as  all,  or  nearly  all,  the 
remedies  which  have  been  employed  successfully  in  the  prevention  or 
cure  of  scurvy,  contain  potash,  such  as  potatoes,  cabbage,  celery, 
lettuce,  lime,  lemon,  and  orange'  juice."  As  regards  the  treatment, 
both  local  and  constitutional  are  required.  The  local  treatment  being 
the  same  as  is  recommended  for  "  mercurial  stomatitis,"  need  not  be 
repeated.  The  constitutional  treatment  consists  in  the  administration 
of  the  vegetable  acids,  such  as  lemonade,  for  example.  Turner's  an- 
tidote, composed  of  potassse  nitratis  3ij,  and  acidi  acetici,  .^viij,  in 
tablespoonful  doses,  three  times  a  day,  is  a  favorite  remedy.  In  con- 
nection with  this.  Dr.  Garretson  recommends  saturating  a  sheet  with 
water  moderately  warm  and  moderately  salt,  which  is  thrown  around 
the  body  each  morning  immediately  on  rising,  and  rubbed  against  the 
flesh  until  a  ruddy  glow  is  excited. 


CHAPTER  IV. 

DISEASES   OF   THE   GUMS. 


LITTLE  can  be  ascertained  concerning  the  innate  constitution  from 
an  inspection  of  the  gums.  Subject  to  the  laws  of  the  general 
economy,  their  appearance  varies  with  the  state  of  the  general  health 
and  the  condition  and  arrangement  of  the  teeth.  Although  the  proxi- 
mate cause  of  disease  in  them  may  be  specified  as  local  irritation — 
produced  by  depositions  of  tartar  upon  the  teeth,  or  decayed,  dead, 
loose  or  irregularly  arranged  teeth,  or  by  a  vitiated  state  of  the  fluids 
of  the  mouth,  resulting  from  general  organic  derangement,  or  any  or 
all  of  the  first-mentioned  causes — their  susceptibility  to  morbid  im- 
pressions is  influenced  to  a  considerable  extent  by  the  constitutional 
health;  and  the  state  of  this  determines,  too,  the  character  of  the 
morbid  effects  produced  upon  them  by  local  irritants.  For  exam^Dle, 
the  deposition  of  a  small  quantity  of  tartar  upon  the  teeth,  or  a  dead 
or  loose  tooth,  would  not,  in  a  healthy  person  of  a  good  constitution, 
give  rise  to  anything  more  than  slight  increased  vascular  action  in  the 
margin  of  the  gums  in  contact  with  it ;  while  in  a  scorbutic  subject,  it 
would  cause  them  to  assume  a  dark  purple  appearance  for  a  consider- 


DISEASES   OF   THE   GUMS.  197 

able  distance  around,  to  become  swollen  and  flabby,  to  separate  and 
retire  from  the  necks  of  the  teeth,  or  to  grow  down  upon  their  crowns, 
to  ulcerate  and  bleed  from  the  slightest  injury,  and  to  exhale  a  fetid 
odor.  In  proportion  as  this  disposition  of  body  exists,  their  liability 
to  be  thus  affected  is  increased  ;  and  it  is  only  among  constitutions  of 
this  kind  that  that  peculiar  preternatural  morbid  growth  takes  place 
by  which  the  whole  of  the  crowns  of  the  teeth  sometimes  become 
almost  entirely  imbedded  in  their  substance. 

But,  notwithstanding  the  dependence  of  the  condition  of  the  gums 
upon  the  state  of  the  constitutional  health,  they  are  occasionally 
aifected  with  sponginess  and  inflammation  in  the  best  temperaments, 
and  in  individuals  of  uninterrupted  good  health.  The  wrong  position 
of  a  tooth,  by  causing  continued  tension  of  the  gums  investing  its 
alveolus,  sooner  or  later  gives  rise  to  chronic  inflammation  in  them 
and  the  alveolo-dental  periosteum,  and  gradual  wasting  of  their  sub- 
stance about  the  mal-placed  organ.  The  causes  of  toothache,  too, 
often  produce  the  same  effects;  the  accumulation  of  salivary  calculus 
upon  teeth,  however  small  the  quantity,  is  likewise  prejudicial. 

All  of  these  may  occur  independently  of  the  state  of  the  general 
health.  A  bad  arrangement  of  the  best  constituted  teeth,  and  toothache 
may  be  produced  by  a  multitude  of  accidental  causes  disconnected 
with  the  functional  operations  of  other  parts  of  the  body. 

While,  therefore,  the  aj^pearance  and  physical  condition  of  this 
peculiar  and  highly  vascular  structure  are  influenced  in  a  great  degree 
by  habit  of  body,  they  are  not  diagnostics  that  always,  and  with 
unerring  certainty,  indicate  the  pathological  state  of  the  general  sys- 
tem. It  can,  however,  in  by  far  the  larger  number  of  cases,  where  the 
gums  are  in  an  unhealthy  condition,  be  readily  ascertained  whether 
the  disease  is  altogether  the  result  of  local  irritation,  or  whether  it  is 
favored  by  constitutional  tendencies. 

In  childhood,  or  during  adolescence,  when  the  formative  forces  of 
the  body  are  all  in  active  operation,  and  the  nervous  susceptibilities 
of  every  part  of  the  organism  highly  acute,  the  sympathy  between  the 
gums  and  other  parts  of  the  system,  and  particularly  the  stomach,  is, 
perhaps,  greater  than  at  any  other  period  of  life.  The  general  health, 
too,  at  this  time  is  more  fluctuating,  and  with  all  the  changes  this 
undergoes,  the  appearances  of  the  gums  vary.  Moreover,  there  are 
operations  carried  on  beneath  and  within  their  substance,  which  are 
almost  constantly  altering  their  appearance  and  physical  condition  ; 
and  which,  being  additionally  influenced  by  various  states  of  health 
and  habits  of  body,  it  may  readily  be  conceived  that  those  met  with 
in  one  case  might  be  looked  for  in  vain  in  another. 

Having  arrived  at  that  age  when  all  the  organs  of  the  body  are  in 


198  DENTAL  PATHOLOGY,  THERAPEUTICS. 

full  vigor  of  maturity,  and  not  under  the  debilitating  influences  to 
which  they  are  subject  during  the  earlier  periods  of  life,  the  gums 
participate  in  the  happy  change,  and,  as  a  consequence,  present  less 
variety  in  their  characteristics.  The  general  irritability  of  the  system 
is  not  now  so  great,  the  gums  are  less  susceptible  to  the  action  of  irri- 
tating agents,  and,  as  a  consequence,  less  frequently  affected  with  dis- 
ease ;  but  as  age  advances,  and  the  vital  energies  begin  to  diminish, 
the  latent  tendencies  of  the  body  are  re-awakened,  and  they  are  again 
easily  excited  to  morbid  action,  and  exhibit  a  darker  color  and  thicker 
structure,  with  a  tendency  to  bleed,  and  such  conditions  in  an  exag- 
gerated form  in  dyspeptic  persons  and  those  subject  to  glandular 
struma. 

In  the  most  perfect  constitutions,  and  during  adolescence,  they  pre- 
sent the  following  appearances:  they  have  a  pale  rose-red  color,  a  firm 
consistence,  a  slightly  uneven  surface,  their  margins  form  along  the 
outer  surfaces  of  the  dental  circle  beautiful  and  regular  festoons,  with  a 
very  thin  edge  around  the  teeth  and  firmly  attached  near  their  necks, 
with  the  interstices  so  filled  up  that  but  little  food  can  collect  between 
the  teeth,  and  the  mucous  membrane  here,  as  well  as  in  other  parts  of 
the  mouth,  has  a  fresh,  lively,  roseate  hue. 

The  time  for  the  eruption  of  a  deciduous  tooth  is  announced  some 
weeks  before  it  takes  place,  by  increased  redness  and  slight  tumefaction 
of  the  edges  and  apices  of  the  gums  surrounding  it.  The  eruption  of  a 
tooth,  whether  of  the  first  or  second  set,  is  also  preceded  by  similar 
phenomena  in  the  gums  through  which  it  is  forcing  its  way,  and  these 
will  be  more  marked  as  the  condition  of  the  system  is  unhealthy,  or  as 
the  habit  of  the  body  is  bad. 

If  the  health  of  the  subject  continues  good,  and  the  teeth  are  well 
arranged,  and  the  necessary  attention  to  their  cleanliness  be  strictly 
observed,  the  characteristics  just  enumerated  will  be  preserved  through 
life,  except  there  will  be  a  slight  diminution  of  color  in  them  after  the 
age  of  puberty  until  that  of  the  climacteric  period  of  life,  when  they  will 
again  assume  a  somewhat  redder  appearance.  But  if  the  health  of  the 
subject  becomes  impaired,  or  the  teeth  be  not  regularly  arranged,  or 
wear  off,  or  are  not  kept  free  from  all  lodgment  of  extraneous  matter, 
their  edges,  and  particularly  their  apices,  will  inflame,  swell,  and 
become  more  than  ordinarily  sensitive. 

The  gradual  wasting  or  destruction  of  the  margins  of  the  gums 
around  the  necks  of  the  teeth,  which  sometimes  takes  place  in  the  best 
constitutions,  and  is  supposed  by  some  to  be  the  result  of  general  atro- 
phy, is  ascribable,  we  have  no  doubt,  to  some  one  or  other  of  these 
causes,  favored,  perhaps,  by  a  diminution  of  vitality  in  the  teeth, 
whereby  they  are  rendered  more  obnoxious  to  the  more  sensitive  and 


DISEASES   OF   THE   GUMS.  199 

vascular  parts  within  which  their  roots  are  situated.  That  these  are 
the  causes  of  the  affection  (for  it  is  evidently  the  result  of  diseased 
action  in  the  gums),  is  rendered  more  than  probable  by  the  fact  that  it 
rarely  occurs  with  those  who,  from  early  childhood,  have  been  in  the 
regular  and  constant  habit  of  thoroughly  cleansing  their  teeth  from 
four  to  five  times  a  day. 

Although  possessed  of  a  good  constitution,  a  person  may,  by  intem- 
perance, debauchery,  or  long  privation  of  the  necessary  comforts  of 
life,  or  by  protracted  febrile  or  other  severe  kinds  of  disease,  have  his 
assimilative  and  all  the  other  organs  of  the  body  so  enervated  as  to 
render  every  part  of  the  system  highly  susceptible  to  morbid  impres- 
sions of  every  sort ;  but  still  this  general  functional  derangement 
rarely  predisposes  the  structure  now  under  consideration  to  any  of  the 
more  malignant  forms  of  disease  occasionally  known  to  attack  it  in 
subjects  of  less  favorable  constitutions.  The  margins  of  the  gums  may 
inflame,  become  turgid,  ulcerate,  and  recede  from  the  necks  of  the 
teeth,  and  the  whole  of  their  substance  be  involved  in  an  unhealthy 
condition ;  but  they  will  seldom  be  attacked  with  scirrhous  or  fungous 
tumors,  or  bad-conditioned  ulcers,  or  affected  with  preternatural  mor- 
bid growths ;  and  in  the  treatment  of  their  diseases  we  can  always 
form  a  more  favorable  prognosis  in  persons  of  this  description  than 
those  coming  into  the  world  with  some  specific  morbid  tendency. 

But  the  occurrence  of  severe  constitutional  disease,  even  in  these 
subjects,  is  followed  by  increased  irritability  of  the  gums,  so  that  the 
slightest  cause  of  local  irritation  gives  rise  to  an  afflux  of  blood  to,  and 
stasis  of  this  fluid  in,  their  capillaries. 

The  teeth  of  persons  thus  happily  constituted  are  endowed  with 
characteristics  such  as  have  been  represented  as  belonging  to  those  of 
the  best  quality.  They  are  of  a  medium  size,  both  in  length  and 
volume,  white,  compact  in  their  structure,  generally  well  arranged, 
and  seldom  affected  with  caries. 

Another  constitution  is  observed,  in  which  the  gums,  though  partak- 
ing somewhat  of  the  characteristics  just  described,  differ  from  them  in 
some  particulars.  Their  color  is  of  a  deeper  vermilion ;  their  edges 
rather  thicker,  their  structure  less  firm,  and  their  surface  not  so  rough, 
but  more  humid.  The  mucous  membrane  has  a  more  lively  and  ani- 
mated appearance.  They  are  more  sensitive  and  more  susceptible  to 
the  action  of  local  irritants,  with  morbid  tendencies  more  increased  by 
general  organic  derangement,  than  when  possessed  of  the  apjDcarances 
first  mentioned. 

When  in  a  morbid  condition,  the  disease,  though  easily  cured  by 
proper  treatment,  is,  nevertheless,  more  obstinate,  and  when  favored 
by  constitutional  derangement,  assumes  a  still  more  aggravated  form. 


200  DENTAL  PATHOLOGY,  THERAPEUTICS. 

Their  predisposition  to  disease  is  so  much  increased  by  long  continued 
disturbance  of  the  general  system,  and  especially  during  youth,  and 
by  febrile  or  inflammatory  affections,  that  not  only  their  margins,  but 
their  whole  substance,  sometimes  become  involved  in  inflammation  and 
sponginess,  followed  by  ulceration  of  their  edges,  and  recession  from 
the  necks  of  the  teeth,  which,  in  consequence,  loosen,  and  often  drop 
out.  But  gums  of  this  kind,  like  those  first  described,  seldom  grow 
down  upon  the  crowns  of  the  teeth.  Neither  are  they  very  liable  to 
be  attacked  with  scirrhous  or  fungous  tumors,  or  any  form  of  disease 
resulting  in  sanious  or  other  malignant  conditioned  ulcers.  Indeed , 
with  diseases  of  this  kind,  they  are  not,  perhaps,  ever  affected,  except 
in  those  cases  where  every  part  of  the  body  has  become  exceedingly 
depraved  by  intemperance,  debauchery,  or  some  other  cause. 

The  teeth  of  those  whose  gums  are  of  this  description,  if  well 
arranged  and  kept  constantly  clean,  and  if  the  secretions  of  the  mouth 
be  not  vitiated  by  general  disease,  will,  in  most  cases,  remain  healthy 
through  life. 

It  is  only  among  sanguineous  persons  that  this  description  of  gums 
is  met  with,  and  the  teeth  of  subjects  of  this  kind  are  generally  of 
excellent  quality,  and  though  more  liable  to  be  attacked  by  caries 
than  those  first  noticed,  they  are  seldom  affected  with  it. 

In  sanguineo-serous  and  strumous  subjects,  the  gums  are  pale,  and 
though  their  margins  are  thin  and  well  festooned,  often  exude,  after 
the  twenty-fifth  and  thirtieth  year,  a  small  quantity  of  muco-purulent 
matter,  which,  on  pressure,  oozes  from  between  them  and  the  necks  of 
the  teeth.  Their  texture  is  usually  firm,  and  they  are  not  very  liable 
to  become  turgid.  They  often  remain  in  this  condition  to  a  late  period 
of  life,  without  undergoing  any  very  perceptible  change.  Their  con- 
nection with  the  necks  of  the  teeth  and  alveolar  processes  appears  weak, 
but  they  rarely  separate  from  them. 

In  individuals  having  such  constitutions,  dyspepsia,  chronic  hepa- 
titis, and  diseases  in  which  the  primce  vice  generally  are  more  or  less 
involved,  are  not  unfrequent,  and  are  indicated  by  increased  irrita- 
bility, and  sometimes  a  pale,  yellowish  appearance  of  the  gums.  In 
jaundice,  the  yellowish  serosity  of  the  blood  is  very  appareut  in  the 
capillaries  of  this  structure. 

These  constitutions  are  more  common  in  females  than  males,  in  the 
rich  than  the  poor,  and  in  persons  of  sedentary  habits  than  in  those 
who  use  invigorating  exercise.  If  at  any  time  during  life  the  health  is 
ameliorated,  the  gums  assume  a  fresher  and  redder  appearance,  and 
the  exudation  of  muco-purulent  matter  from  between  them  and  the 
necks  of  the  teeth  ceases. 

In  mucous  dispositions,  the  gums  have  a   smooth,  shining  appear- 


DISEASES   OP   THE   GUMS.  201 

ance,  and  are  rather  more  highly  colored  than  the  preceding.  Their 
margins,  also,  are  thicker,  more  flabby,  and  not  so  deeply  festooned  ; 
they  are  more  irritable,  and,  consequently,  more  susceptible  to  morbid 
impressions. 

If,  with  this  disposition,  there  be  combined  a  scorbutic  or  scrofulous 
tendency,  the  gums  during  early  childhood,  in  subjects  which,  from 
scanty  and  unwholesome  diet,  have  become  greatly  debilitated,  are 
liable,  besides  the  ordinary  forms  of  disease,  to  another — characterized 
by  their  separation  from,  and  exfoliation  of,  the  alveolar  processes, 
accompanied  by  a  constant  discharge  of  sanies.  This  form  of  disease, 
however,  though  peculiar  to  childhood,  and  wholly  confined  to  the 
indigent,  is  by  no  means  common. 

These  constitutions  are  rarely  met  with,  except  among  persons  who 
live  in  cellars,  and  damp  and  closely  confined  rooms  in  large  cities, 
and  in  low,  damp,  and  sickly  districts  of  country.  The  mucous  mem- 
brane in  subjects  of  this  kind  is  exceedingly  irritable,  and  secretes  a 
large  quantity  of  mucus. 

Persons  even  thus  unhappily  constituted  do,  sometimes,  by  change 
of  residence  and  judicious  regimen,  acquire  tolerably  good  constitutions. 
Little  advantage,  however  is  derived  from  these,  unless  they  are  had 
recourse  to  before  the  twenty-fifth  or  thirtieth  year  of  age,  though  they 
may  prove  beneficial  at  a  much  later  period. 

The  gums  in  scorbutic  persons  have  a  reddish-brown  color ;  their 
margins  are  imperfectly  festooned  and  thick  ;  their  structure  rather 
disposed  to  become  turgid,  and  ever  ready,  on  the  presence  of  the 
slightest  cause  of  local  irritation,  to  take  on  a  moroid  action.  When 
thus  excited,  the  blood  accumulates  in  their  vessels,  where,  from  its 
highly  carbonized  state,  it  gives  to  the  gums  a  dark  purple  or  brown 
appearance ;  they  swell,  and  become  spongy  and  flabby,  and  bleed 
from  the  slightest  touch.  To  these  symptoms  supervene  the  exhala- 
tion of  a  fetid  odor,  the  destruction  of  the  bond  of  union  between  them 
and  the  necks  of  the  teeth,  suppuration  and  recession  of  their  margins 
from  the  same  gradual  wasting  of  the  alveolar  cavities,  loosening,  and, 
not  unfrequently,  the  loss  of  several  or  the  whole  of  the  teeth.  These 
are  the  most  common  results,  but  sometimes  they  take  on  other  and 
more  aggravated  forms  of  diseased  action:  preternatural,  prurient 
growths  of  their  substance,  fungous  and  scirrhous  tumors,  ichorous  and 
other  malignant  and  ill-conditioned  ulcers,  etc. 

The  occurrence  of  alveolar  abscesses  in  dispositions  of  this  kind  is 
often  followed  by  necrosis  and  exfoliation  of  portions  of  the  maxillary 
bone,  and  the  effects  which  result  to  the  gums  are  always  more  per- 
nicious than  in  habits  less  depraved. 

The  development  of  the  morbid  changes  which  take  place  in  this 


202  DENTAL   PATHOLOGY,  THERAPEUTICS. 

structure,  even  in  subjects  of  this  kind,  while  the  character  of  the  dis- 
ease is  influenced,  if  not  determined,  by  a  specific  constitutional  ten- 
dency, is,  nevertheless,  referable  to  local  irritation  as  the  immediate  or 
proximate  cause,  and  were  this  the  proper  place,  we  could  cite  numer- 
ous cases  tending  to  establish  the  truth  of  this  opinion. 

In  scrofulous  habits,  the  gums  have  a  pale  bluish  appearance,  and 
when  subjected  to  local  irritation,  they  become  flabby,  exhale  a  nau- 
seating odor,  detach  themselves  from  the  necks  of  the  teeth,  and  their 
apices  grow  down  between  these  organs.  The  blood  circulates  in  them 
languidly,  and  debility  seems  to  pervade  their  whole  substance. 
They  are  exceedingly  irritable,  and  not  unfrequently  take  ou  aggra- 
vated forms  of  disease,  and  as  often  happens  to  this  as  well  as  to  the 
preceding  habit,  there  are  combined  tendencies  which  favor  the  pro- 
duction of  ill-conditioned  tumors  and  ulcers. 

The  indications  furnished  by  the  gums  during  the  existence  of  a 
mercurial  diathesis  of  the  system  are  morbid  sensibility,  increased 
vascular  and  glandular  action,  foulness,  bleeding  from  the  most  trifling 
injuries,  pale  bluish  appearance  of  their  substances,  turgidity  of  their 
apices,  and  sloughing.  The  effects,  however,  resulting  to  these  parts 
from  the  employment  of  mercury  differ  in  different  individuals,  accord- 
ing to  the  general  constitutional  susceptibility,  the  quantity  taken  into 
the  system,  and  the  length  of  time  its  use  has  been  continued.  In 
persons  of  very  irritable  habits,  a  single  dose  will  sometimes  produce 
ptyalism,  and  so  increase  the  susceptibility  of  the  gums  that  the  secre- 
tions of  the  mouth,  in  their  altered  state,  will  at  once  rouse  up  a  mor- 
bid action  in  them. 

The  effects  of  a  mercurial  diathesis  upon  these  parts  is  not  unfre- 
quently so  great  as  to  result  in  the  loss  of  the  whole  of  the  teeth. 
But  with  these  effects  both  the  dental  and  medical  practitioner  are  too 
familiar  to  require  any  further  description. 

Finally,  we  would  observe,  that  the  indications  of  the  several  char- 
acteristics to  which  we  have  now  briefly  alluded  may  not  be  correct  in 
every  particular,  and  there  are  others  which  we  have  not  mentioned ; 
yet  we  think  they  will  commonly  be  found  true.  As  a  general  rule, 
persons  of  a  full  habit,  though  possessed  of  mixed  temperaments  and 
in  the  enjoyment  of  what  is  usually  called  good  health,  have  gums  well 
colored,  with  rather  thick  margins,  and  very  susceptible  to  local  irri- 
tation. With  this  description  of  individuals,  inflammation,  turgidity, 
and  suppuration  of  the  gums  are  very  common.  To  prevent  these 
effects,  constant  attention  to  the  cleanliness  of  the  teeth  is  indispensable. 

Prof.  Schill  says,  the  "  gum  is  pale  in  chlorosis  anaemia ;  of  a 
purple-red  color  before  an  active  hemorrhoidal  discharge  and  in  cases 
of  dysmenorrhoea ;  of  a  dark  red  color,  spongy,  and  bleeding  readily. 


INFLAMMATION   OF   THE   GUMS.  203 

in  scurvy  and  diabetes  mellitus,  and  after  the  use  of  mercury.  Spongy 
growths  indicate  caries  of  the  subjacent  bone." 

Regular  periodical  bleedings  of  the  gums  in  dysmenorrhoea,  and 
particularly  in  scorbutic  and  mucous  subjects,  are  not  unfrequent,  nor 
in  any  case  where  they  are  in  a  turgid  condition. 

Spongy  growths  of  the  gums  in  scorbutic  and  scrofulous  persons 
often  result  from  irritation  produced  by  decayed  teeth,  and  are  not, 
therefore,  always  to  be  regarded  as  an  indication  of  caries  of  the  sub- 
jacent bone. 

Dr.  T.  Thompson,  of  London,  says  that  the  reflected  margin  of  the 
gums  of  a  large  majority  of  phthisical  patients  is  deeper  in  color  than 
the  other  portions  usually  presenting  a  vermilion  tint. 

Mr.  George  Waite  says,  "  A  change  of  residence  to  a  damp  climate 
will  often  rouse  up  in  the  gums  a  great  degree  of  vascularity.  In  the 
damp  places  of  England  and  Ireland  the  appearances  which  the  gums 
present  are  of  a  turgid  and  vascular  nature.  In  the  damp  countries 
of  France,  these  conditions  of  the  gums  run  a  much  greater  length, 
from  the  circumstance  of  the  difference  in  the  constitutions  of  the  two 
nations.  In  the  damps  of  Germany  and  Switzerland  persons  also  lose 
their  teeth  early  in  life ;  the  climate  engenders  malaria  and  low  fevers, 
enfeebles  the  power  of  digestion,  and  brings  on  rheumatic  affections, 
with  languor  and  general  constitutional  debility." 

Of  the  correctness  of  Mr.  Waite's  observations  there  can  be  no 
question,  and  they  go  to  establish  what  has  been  said  in  regard  to  the 
predisposing  cause  of  disease  in  the  gums  ;  namely,  that  the  enervation 
of  the  vital  powers  of  the  body,  from  whatever  cause  produced,  in- 
creases their  susceptibility  to  morbid  impressions. 

INFLAMMATION   OF   THE   GUMS. 

The  gums  and  alveolar  processes,  from  apparently  the  same  cause, 
frequently  assume  various  morbid  conditions.  An  unhealthy  action 
in  one  is  almost  certain  to  be  followed  by  disease  in  the  other.  The 
most  common  form  of  disease  to  which  these  parts  are  subject  is  usually, 
though  very  improperly,  denominated  scurvy,  from  its  supposed  re- 
semblance to  scorbutus,  a  disease  to  which,  however,  it  bears  no  resem- 
blance. Instead,  therefore,  of  continuing  the  use  of  this  term,  we 
propose  to  treat  the  disease  under  the  name  of  chronic  inflammation 
and  tumefaction  of  the  gums,  attended  by  recession  of  their  margins  from 
the  necks  of  the  teeth,  which  seems  to  express  more  clearly  the  condition 
of  the  parts  and  the  nature  of  the  disease.  The  gums  sometimes, 
though  less  frequently,  become  the  seat  of  acute  inflammation.  The 
other  affections  to  which  they  are  liable  will  be  noticed  in  their 
appropriate  place. 


204  DENTAL   PATHOLOGY,  THERAPEUTICS. 

The  diseases  of  the  gums  and  alveolar  processes  are  divided  by  Mr. 
Bell  into  two  classes  :  those  which  are  the  result  of  local  irritation, 
and  those  which  arise  from  constitutional  causes. 

Were  it  not  for  local  irritation  in  these  parts,  the  constitutional 
tendencies  to  disease  would  rarely  manifest  themselves  ;  and,  on  the 
other  hand,  were  it  not  for  constitutional  tendencies,  the  effects  of 
local  irritation  would  seldom  be  of  a  serious  character.  "  Thus,"  says 
Mr.  Bell,  "the  same  cause  of  irritation  which,  in  a  healthy  person, 
would  occasion  a  simple  abscess,  might,  in  a  different  constitution,  re- 
sult in  ulceration  of  a  decidedly  cancerous  type,  or  in  the  production 
of  fungous  tumors,  or  the  formation  of  scrofulous  abscesses." 

Each  constitution  has  its  peculiar  tendency ;  or,  in  other  words,  is 
more  favorable  to  the  development  of  some  foi'ms  of  disease  than 
others ;  and  this  tendency  is  always  increased  or  diminished  accord- 
ing to  the  healthy  or  unhealthy  performance  of  the  functional  opera- 
tions of  the  body  generally.  Thus,  derangement  of  the  digestive 
organs  increases  the  tendency,  in  an  individual  of  a  mucous  habit,  to 
certain  forms  of  diseased  action  in  particular  organs,  and  especially 
in  the  gums.  A  local  irritant,  which  would  otherwise  produce 
only  a  slight  inflammation  of  the  margins  of  the  gums,  would  now 
give  rise  to  turgidity  and  sponginess  of  their  whole  structure.  The 
same  may  be  said  with  regard  to  a  person  of  a  scrofulous  or  scorbutic 
habit. 

The  susceptibility  of  the  gums  to  the  action  of  morbid  irritants  is 
always  increased  by  enfeeblement  of  the  vital  powers  of  the  body. 
Hence,  persons  laboring  under  excessive  grief,  melancholy,  or  any 
other  affection  of  the  mind,  or  under  constitutional  disease  tending  to 
enervate  the  vital  energies  of  the  system,  are  exceedingly  subject  to 
inflammation,  sponginess,  and  ulceration  of  the  gums.  But,  notwith- 
standing the  increase  of  susceptibility  which  the  gums  derive  from 
certain  constitutional  causes  and  states  of  the  general  health,  these 
influences  may,  in  the  majority  of  cases,  be  counteracted  by  a  strict 
observance  of  the  rules  of  dental  hygiene ;  or,  in  other  words,  by 
constant  and  regular  attention  to  the  cleanliness  of  the  teeth. 

A  local  disease,  situated  in  a  remote  part,  often  has  the  effect  of 
diminishing  the  tendency  in  the  gums  to  disease ;  but  when,  from  its 
violence  or  long  continuance,  the  general  health  becomes  implicated, 
the  susceptibility  of  these  parts  is  augmented. 

Although  deriving  their  predisposition  to  disease  from  a  specific, 
morbid  constitutional  tendency,  they,  nevertheless,  when  diseased, 
contribute  in  no  small  degree  to  derange  the  whole  organism.  Their 
unhealthy  action  vitiates  the  fluids  of  the  mouth,  and  renders  them 
unfit  for  the  purposes  for  which  they  are  designed  ;  hence,  when  these 


INFLAMMATION   OF   THE   GUMS.  205 

parts  are  restored  to  health,  whether  from  the  loss  of  diseased  teeth, 
or  the  treatment  to  which  they  may  have  been  subjected,  the  condition 
of  the  general  health  is  always  immediately  improved. 

Thus,  while  the  susceptibility  of  the  gums  to  morbid  impressions  is 
influenced  by  the  state  of  the  general  health,  the  latter  is  equally 
influenced  by  the  condition  of  the  former.  And  not  only  is  a  healthy 
condition  of  the  gums  essential  to  the  general  health,  but  it  is  also 
essential  to  the  health  of  the  teeth  and  alveolar  processes.  From  the 
intimate  relation  that  subsists  between  the  former  and  the  latter, 
disease  cannot  exist  in  one  without  in  some  degree  affecting  the  other. 
Caries  of  the  teeth,  for  example,  often  gives  rise  to  inflammation  of 
the  gums  and  alveolo-dental  periosteum ;  on  the  other  hand,  inflam- 
mation of  these  parts  vitiates  the  fluids  of  the  mouth  and  causes  them 
to  exert  a  deleterious  action  upon  the  teeth,  and  also  excites  more  or 
less  constitutional  derangement. 

ACUTE   INFLAMMATION   OF   THE   GUMS. 

Acute  inflammation  of  the  gums  frequently  occurs  in  connection 
with  stomatitis,  or  general  inflammation  of  the  mucous  membrane 
of  the  buccal  cavity,  which  appears  under  a  great  variety  of  forms. 
In  this  case  the  inflammatory  action  does  not  always  extend  to  the 
subjacent  fibro-cartilaginous  structure;  but  the  local  disease  is  often 
complicated  with  other  disorders,  the  treatment  of  which  comes  more 
properly  within  the  province  of  the  medical  than  that  of  the  dental 
practitioner.  Ulitis,  or  acute  inflammation  of  the  gums,  is,  in  most 
cases,  a  purely  local  disease,  arising  usually  from  the  irritation  of 
dentition,  or  as  a  consequence  of  periodontitis.  It  often  extends  to 
the  submaxillary  glands  and  muscles  of  the  face,  and  is  attended  by 
swelling  and  other  morbid  phenomena.  But  as  this  form  of  inflam- 
mation of  the  gums  is  treated  of  in  connection  with  other  subjects, 
it  will  not  be  necessary  to  repeat  what  we  have  said  elsewhere 
concerning  it. 

CHRONIC  INFLAMMATION  AND  TUMEFACTION  OF  THE  GUMS  ATTENDED 
BY    RECESSION    OF   THEIR   MARGINS    FROM    THE   TEETH. 

Chronic  inflammation  of  the  gums  may  exist  for  years  without  being 
attended  with  suppuration  or  recession  of  their  margins  from  the 
necks  of  the  teeth  ;  but  these  phenomena  are  sooner  or  later  developed, 
according  to  the  amount  of  local  irritation  and  the  state  of  the  consti- 
tutional health  and  habit  of  body.  With  the  occurrence  of  inflamma- 
tion the  margins  of  the  gums  gradually  lose  their  festooned  appearance, 
become  thick,  spongy,  and  rounded,  and  ultimately,  on  being  pressed, 
.purulent  matter  is  discharged  from  between  them  and  the  necks  of 


206 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


Fig.  77. 


the  teeth.     Their  sensibility  is  increased,  and  they  bleed  from  the  most 
trifling  injury. 

The  diseased  action  usually  first  develops  itself  in  the  gums  around 
tlie  lower  front  teeth  and  the  upper  molars,  opposite  the  mouths  of 
the  salivary  ducts,  also  in  the  immediate  vicinity  of  aching,  decayed, 
dead,  loose,  or  irregularly  arranged  teeth,  or  in  the  neighborhood  of 
roots  of  teeth ;  from  thence  it  extends  to  the  other  teeth.  The  rapidity 
of  its  progress  depends  on  the  age,  state  of  the  general  health,  tempera- 
ment and  habit  of  body  of  the  individual,  and  the  character  of  the 
local  irritant  which  has  given  rise  to  it.  It  is  always  more  rapid  in 
persons  addicted  to  the  free  use  of  spirituous  liquors,  and  in  individuals 
in  whom  there  exists  a  scorbutic  tendency,  or  who  have  suflfered  from 
venereal  disease,  or  from  the  constitutional  effects  of  a  mercurial  treat- 
ment used  to  cure  this  or  other  diseases. 

The  inflammation  may  be  confined  to  the  gums  of  two  or  three  teeth, 
or  it  may  extend  to  the  gums  of  all  the  teeth  in  one  or  both  jaws. 

As  the  disease  advances,  the 
gums  begin  to  recede  from  the 
necks  of  the  teeth,  and  the  alveoli 
to  waste,  and  the  teeth,  as  they  lose 
their  support,  loosen  and  ultimately 
drop  out.  In  Fig.  77  is  repre- 
sented a  case  in  which  nearly  one- 
half  of  the  roots  of  the  lower  in- 
cisors have  become  exposed  by  this 
devastating  process. 
But  the  loss  of  the  teeth,  though  it  puts  a  stop  to  the  local  disease, 
is  not  the  only  bad  effect  that  results  from  it.  Constitutional  symp- 
toms often  supervene,  more  vital  organs  become  implicated,  and  the 
health  of  the  general  system  is  sometimes  very  seriously  impaired. 
Hence,  the  improvement  often  observed  after  the  loss  of  the  teeth,  in 
the  general  health  of  persons  whose  mouths  have  for  a  long  time  been 
affected  with  this  disease.  No  condition  of  the  mouth  has  a  greater 
tendency  to  deteriorate  its  secretions  and  impair  the  functions  of  ma.s- 
tication  and  digestion,  than  the  one  under  consideration. 

In  forming  an  opinion  of  the  injury  likely  to  result  from  the  disease, 
the  dentist  should  be  governed  not  only  by  the  health  and  age  of  the 
patient,  and  the  local  causes  concerned  in  its  production,  but  he 
should  also  endeavor  to  ascertain  whether  it  is  connected  with  a  con- 
stitutional tendency,  or  is  purely  a  local  affection.  Some  have  been 
led  to  believe  that  the  wasting  of  the  gums  and  alveolar  processes 
may  sometimes  take  place  without  being  connected  with  any  special, 
local,  or  constitutional  cause ;  that  it  is  identical  with  that  process  by 


INFLAMMATION   OF   THE   GUMS.  207 

which  the  teeth  of  aged  persons  are  removed,  and  that  when  it  occurs 
in  persons  not  past  the  meridian  of  life,  it  is  symptomatic  of  a  kind  of 
premature  old  age. 

The  loss  of  the  teeth,  from  the  wasting  of  the  gums  and  alveolar 
processes,  although  occurring  frequently  in  advanced  life,  is  not  a 
necessary  consequence  of  senility,  for  we  occasionally  see  persons  of 
seventy,  and  even  eighty  years  of  age,  whose  teeth  are  as  firmly  fixed 
in  their  sockets,  and  their  gums  as  little  impaired,  as  in  individuals  at 
twenty.  We  do  not  recollect  ever  to  have  seen  a  case  of  this  kind  in 
which  there  was  not  evidently  some  diseased  action  of  the  gums.  But 
it  is  of  little  importance  whether  it  be  the  result  of  old  age,  a  consti- 
tutional tendency,  functional  derangement  of  some  other  part,  or  local 
irritation,  since  the  consequences  resulting  from  such  loss  are  always 
the  same. 

The  gums,  after  having  been  once  the  seat  of  chronic  inflammation, 
are  ever  after  more  susceptible  to  the  action  of  morbid  irritants. 

CAUSES. 

The  immediate  or  exciting  cause  of  inflammation  of  the  gums  is 
local  irritation,  produced  by  salivary  calculus,  by  carious,  dead,  loose 
or  aching  teeth,  or  roots  of  teeth,  or  by  teeth  which  occupy  a  wrong 
position,  or  that  are  crowded  in  their  arrangement.  It  may  also  be 
produced  by  very  hard  teeth,  which,  in  consequence  of  their  density, 
possess  only  a  very  low  degree  of  vitality  ;  for  cases  of  recession  of  the 
gums,  in  which  a  very  slight  inflammatory  action  exists,  are  frequently 
met  with  in  individuals  having  teeth  of  this  description.  This  can 
only  be  explained,  by  supposing  a  want  of  congeniality  between  these 
organs  and  the  more  sensitive  and  highly  vitalized  parts  with  which 
they  are  in  immediate  contact.  The  same  thing  is  observed  when  the 
vitality  of  the  teeth  is  weakened  by  age. 

The  secretions  of  the  mouth,  especially  the  mucus,  are  often  ren- 
dered, by  certain  conditions  of  the  general  system,  so  acrid  as  to 
become  a  source  of  irritation  to  the  gums. 

Dr.  Koecker,  who  had  the  most  ample  opportunities  of  observing 
this  afiection  in  all  its  various  forms,  says  that  he  has  never  seen  a  case 
in  which  tartar  was  not  present.  That  this  is  so  in  a  large  majority  of 
the  cases,  there  is  no  question ;  but  that  it  is  in  all,  is  certainly  a 
mistake.  The  author  has  met  with  many  in  which  not  the  smallest 
deposit  could  be  detected. 

The  disease  attacks  persons  of  every  age,  rank  and  condition  ;  and 
in  every  country,  climate  and  nation. 

It  is,  however,  more  frequently  met  with  in  the  lower  than  in  the 
higher  classes  of  society.     Persons  who  pay  no  attention  to  the  clean- 


208  DENTAL  PATHOLOGY,  THERAPEUTICS. 

liness  and  health  of  their  teeth  are  particularly  subject  to  it.  With 
sailors,  and  those  who  live  principally  on  salt  provisions,  it  is  very 
common.  "  Persons  of  robust  constitution,"  says  Dr.  Koecker,  "  are 
much  more  liable  to  this  affection  of  the  gums  than  those  of  delicate 
habit ;  and  it  shows  itself  in  its  worst  form  after  the  age  of  thirty 
oftener  than  at  any  earlier  period." 

To  the  causes  of  irritation  which  have  already  been  enumerated,  may 
be  added,  uncleanly  habits  which  cause  the  accumulation  of  extraneous 
matters  on  the  teeth  and  along  the  edges  of  the  gums,  which  decompose, 
producing  irritation  and  increased  vascular  action,  followed  by  conges- 
tion, stagnation  and  general  breaking  down  of  tissue,  and  the  secretion 
of  pus;  also  mercurial  poisoning;  scurvy;  syphilis;  a  crowded  dental 
arch ;  malignant  impressions ;  artificial  teeth  badly  inserted,  or  made 
of  improper  material ;  and  dental  operations  badly  performed.  The 
use  of  improper  tooth-brushes  and  powders,  especially  charcoal,  may 
be  reckoned  among  its  exciting  causes.  The  irritability  of  the 
gums  is  sometimes  increased  by  the  use  of  acids ;  at  other  times  it 
is  diminished. 

Every  condition  of  the  general  system  tending  to  increase  the 
susceptibility  of  the  gums  to  the  action  of  local  irritants  favors  the 
production  of  the  disease.  Everything  that  tends  to  induce  such 
conditions  may  be  regarded  as  a  predisposing  cause ;  such  as  bilious 
and  inflammatory  fevers,  the  excessive  use  of  mercurial  medicines,  the 
venereal  virus,  intemperance  and  debauchery.  Any  deterioration  of 
the  fluids  of  the  body  is  peculiarly  conducive  to  it.  Persons  of 
cachectic  habit  are  far  more  subject  to  it,  and  generally  in  its  worst 
forms,  than  those  individuals  in  the  enjoyment  of  good  health. 

Strumous  individuals  sometimes  have  an  afiection  of  the  gums  which 
differs  in  many  respects  from  the  one  just  described.  The  gums, 
instead  of  being  purple  and  swollen,  are  pale  and  harder  than  ordinary, 
and,  on  being  pressed,  discharge  muco-purulent  matter  of  a  dingy 
white  color.  They  often  remain  in  this  condition  for  years,  without 
appearing  to  undergo  any  structural  alteration,  or  to  affect  the  alveo- 
lar processes.  This  form  of  the  disease  is  principally  confined  to  per- 
sons who  have  very  white  teeth  ;  it  is  much  less  likely  to  attack  males 
than  females  ;  and  has  never,  so  far  as  we  have  been  able  to  ascertain, 
been  mentioned  by  any  dental  writer.  It  rarely  occurs  before  the  age 
of  eighteen  or  twenty ;  and  it  seems  to  be  the  result  of  impaired  nutri- 
tion. The  gums  exhibit  no  signs  of  inflammatory  action  ;  on  the  con- 
trary, they  are  i^aler,  less  sensitive,  and  possess  less  wai-mth  than  usual. 
It  is  never  attended  with  tumefaction  or  absorption,  except  in  its 
advanced  stages. 


INFLAMMATION   OF   THE   GUMS.  209 

TREATMENT. 

In  the  treatment  of  inflamed,  spongy,  and  ulcerated  gums,  the  first 
thing  claiming  attention  is  the  removal  of  the  exciting  causes.  If 
there  are  dead  or  loose  teeth  in  the  mouth,  or  teeth  which,  from  their 
position,  act  as  mechanical  irritants,  they  should  be  at  once  extracted. 
The  remaining  teeth  should,  at  the  same  time,  be  freed  from  tartar, 
and  all  other  irritating  depositions,  in  such  a  thorough  manner  as  to 
permit  none  to  remain,  either  about  the  necks  or  beneath  the  margins 
of  the  gums ;  and,  if  necessary,  all  deposits  should  be  removed  from  about 
the  very  ends  of  the  roots  of  the  teeth,  so  far,  at  least,  as  the  separation 
of  the  gums  from  the  teeth  extends.  All  necrosed  portions  of  process 
should  also  be  removed,  and  the  entire  surfaces  of  the  exposed  portions 
of  the  roots  of  the  teeth  be  well  polished.  Besides  removing  the  tartar, 
if  the  gums  are  much  congested,  they  should  be  scarified  around  the 
necks  of  the  teeth  and  all  hypertrophied  growths  in  the  interstices  cut 
away.  The  bleeding  which  follows  such  operations  should  be  pro- 
moted by  frequently  rinsing  the  mouth  with  warm  water. 

It  is  essential,  in  the  treatment  of  the  disease  under  consideration, 
that  a  decided  impression  be  made  upon  it  at  once ;  consequently,  no 
time  should  be  lost  in  the  removal  of  local  exciting  causes.  "  The 
advantage  derived  from  this  operation  "  (extraction  of  dead,  loose,  or 
irritating  teeth),  says  Dr.  Koecker,  "  would  be  either  partly  or  wholly 
lost,  were  it  performed  at  difierent  periods."  This  observation  has 
been  verified  by  the  author  more  than  once.  When  he  has  been  pre- 
vented, by  the  timidity  of  his  patient,  from  extracting  all  the  offending 
teeth  at  the  first  sitting,  he  has  always  found  the  cure  much  retarded, 
and,  in  some  instances,  almost  entirely  defeated. 

Several  sittings,  however,  are  often  required  for  the  complete  re- 
moval of  the  salivary  deposit. 

The  cure  may  be  hastened  by  washing  the  mouth  several  times  a 
day  with  some  tonic  and  astringent  lotion.  The  author  has  found  the 
following  to  be  very  serviceable : — 

R .     Powdered  nutgalls, 

"         Peruvian  bark. ...each,  2  drachms 

"         orris  root 1  drachm 

Infusion  of  roses 4  fluidounces. 

The  infusion  to  stand  for  a  day  or  so  upon  the  powders,  with  frequent  stirring ; 
then  decant  and  filter.    < 

In  mild  cases  of  inflammation  of  the  gums  and  mucous  membrane 
of  the  mouth,  iodine  in  glycerine — saturated  solution — is  an  excellent 
application.  For  acute  inflammation  of  the  mucous  membrane,  the 
following  recipes  will  prove  very  serviceable  as  gargles : — 

14 


210  DENTAL  PATHOLOGY,  THERAPEUTICS. 

R .     PotassiB  cliloras, 

Soda3  boras aa 5J 

Aqu« 5ij.      M. 

R .     Potassas  chloras, 

Alumina  sulphas aa 3J 

Aquae 5iv.     M. 

R.     Acidum  tannicum 3j 

Potassse  chloras ^ij 

Mel.  rosa SJ 

Aqua  buUiens Oj.        M. 

R.     Aquje  Cologn ,^j 

Tinctura  capsici  comp ^j 

Sodse  boras ^ij 

Tinct.  cinchonse ^ij 

Tinct.  pyrethri .^j 

Aquae ^iij.     M. — Garretson. 

We  have,  in  cases  where  there  was  much  soreness  and  ulceration  of 
the  gums,  prescribed  the  following : — 

R.     Borax 2  scruples 

Honey 1  fluidounce 

Sage  tea 4  fluidounces. 

This  is  a  favorite  and  very  general  domestic  remedy,  and  will  be  found  very 
soothing  and  healing. 

For  ulceration  of  the  gums  and  mucous  membrane  of  the  mouth, 
the  following  will  prove  excellent  applications : — 

R.     Acid,  carbolic 5^3 

Glycerini 3xv.    M. 

R.     Sodae  boras ^ij 

Glycerini SJ 

Aquae 3iv.     M. 

R.     Acid,  carbolic gtt.  v 

Glycerini 5J 

01.  caryophylli gtt.  v.  M. 

R.     Sodae  sulphis 3J 

Glycerini Jj.       M. 

As  a  wash  for  the  mouth,  Dr.  Fitch  recommends  a  decoction  of 
the  green  inner  bark  of  white  oak,  which  we  have  found  beneficial. 
The  following  are  recommended  by  Dr.  Koecker  as  being  very  ser- 
viceable : — 


each 1  ounce 


INFLAMMATION   OF   THE   GUMS.  211 

"  Take  of  clarified  honey,  and  of  the  tincture  of  bark,  two  ounces 
each.  Mix  and  dilute  in  the  proportion  of  three  tablespoonfuls  to  a 
pint  of  warm  sage  tea  or  water.  It  may  be  used  frequently  during 
the  day. 

"  Take  of  honey,  and  of  the  tincture  of  myrrh,  two  ounces  each. 
Mix  and  use  as  above." 

For  soft,  swollen  and  spongy  gums,  the  French  preparation  known 
as  Phenole  Sodique — pheuate  of  soda — a-teaspoonful  to  a  tumbler  of 
water,  will  prove  beneficial. 

The  pleasantest,  and  at  the  same  time  the  most  efficacious,  mouth- 
wash which  the  author  has  ever  employed  is  the  following : — 

K.     South  American  soap  bark Bounces 

Pyrethrum, 
Orris  root, 
Benzoic  acid, 
Cinnamon, 

Tannic  acid 4  drachms 

Borax 4  scruples 

Oil  of  wintergreen 2  fluiddrachms. 

Oil  of  peppermint 4  " 

Cochineal 3  drachms 

White  sugar 1  pound 

Alcohol 3  pints 

Pure  water 5     " 

Mix  the  ingredients  thoroughly  ;  digest  for  six  days,  and  filter. 

If,  notwithstanding  the  use  of  the  means  here  recommended,  matter 
still  be  discharged  from  around  the  necks  of  the  teeth,  and  should  the 
gums  continue  spongy,  and  manifest  no  disposition  to  heal,  their  edges 
may  be  touched  with  a  strong  solution  of  the  nitrate  of  silver.  This 
will  seldom  fail  to  impart  to  them  a  healthy  action.  It  may  be  used 
in  the  proportion  of  from  three  to  twelve  grains  to  one  ounce  of  water. 
The  most  convenient  mode  of  applying  it,  is  with  a  camel's-hair  pencil, 
and  it  will  often  succeed  when  other  remedies  fail.  In  those  cases 
where  the  matter  discharged  from  the  edge  of  the  gum  has  a  nause- 
ating and  disagreeable  odor,  a  weak  solution  is  an  excellent  remedy  for 
rendering  the  mouth  comfortable ;  but  in  using  it  in  this  way,  23re- 
caution  is  necessary  to  prevent  it  from  getting  into  the  fauces,  as  iu 
this  case  it  will  cause  disagreeable  nausea.  An  excellent  disinfectant 
iu  such  cases  is  a  gargle  made  by  diluting  a  teaspoonful  of  chlorinated 
soda  (Labarraque's  solution)  in  four  or  eight  ounces  of  water.  Or  it 
may  be  used  much  stronger,  and  applied  with  a  small  mop  to  the  dis- 
eased parts ;  the  silver  nitrate  may  be  applied  in  the  same  way. 

While  the  means  here  directed  for  the  cure  of  the  disease  are  beine- 
employed,  a  recurrence   of  its   exciting   causes   must   be  studiously 


212  DENTAL  PATHOLOGY,  THERAPEUTICS. 

o-uarded  against.  Tartar  and  foreign  matter  of  every  kind  should  be 
prevented  from  accumulating  on  the  teeth,  by  a  free  and  frequent  use 
of  a  suitable  brush  and  waxed  floss-silk,  until  a  healthy  action  be 
imparted  to  the  gums ;  these  should  be  used  at  least  five  times  a  day, 
immediately  after  rising  in  the  morning,  after  each  meal,  and  before 
retiring  at  night.  The  application  of  the  brush  may  at  first  occasion 
some  pain ;  but  its  use  should  nevertheless  be  persisted  in,  for,  without 
it,  all  the  other  remedies  will  be  of  little  avail.  The  friction  produced 
by  it,  besides  keeping  the  teeth  clean,  is  of  great  service  to  the  gums, 
in  imparting  to  them  a  healthy  action. 

Treatment  different  from  that  here  described  is  necessary  in  that 
form  of  disease  which  we  noticed  as  being  characterized  by  preter- 
natural paleness  and  discharge  of  muco-purulent  matter  from  between 
the  edo-e  of  the  gum  and  the  neck  of  the  tooth.  In  the  first  case  of 
this  disease  treated  by  the  author,  he  directed  astringent  and  detergent 
lotions  to  be  used ;  but  these  did  not  produce  the  desired  effect. 
Having  been  led,  from  his  observation  in  this  case,  to  suspect  that  the 
disease  was  connected  with  some  constitutional  derangement,  and  was 
probably  the  result  of  a  debilitated  condition  of  the  general  system, 
he  recommended,  in  the  next  case,  the  use  of  tonics  and  free  exercise 
in  the  open  air.  This  course,  though  attended  with  evident  improve- 
ment of  the  general  health,  seemed  to  be  productive  of  no  benefit  to 
the  gums.  They  still  appeared  debilitated,  and  on  being  pressed  dis- 
charo-ed  matter  from  beneath  their  edges.  He  advised  a  continuance 
of  the  tonics  and  exercise,  and,  with  a  view  of  exciting  inflammation, 
touched  the  edges  of  the  gums  with  nitrate  of  silver.  This  had  the 
desired  effect,  and,  as  he  had  anticipated,  a  new  disease  was  substituted 
for  the  old  one ;  for  the  cure  of  which  he  directed  the  mouth  to  be 
'trashed,  five  or  six  times  a  day,  with  the  mixture  of  sage  tea,  alum 
and  honey,  and  at  night  and  morning  with  salt  water. 

This  treatment  was  perfectly  successful.  In  about  three  weeks  the 
gums  assumed  a  healthy  appearance,  acquired  their  natural  color,  and 
the  discharge  of  muco-purulent  matter  entirely  ceased.  He  has  since 
had  occasion  to  treat  several  other  cases,  in  all  of  which  he  adopted 
the  same  treatment,  and  with  like  success. 

HYPERTROPHY,  OR  MORBID  GROWTH  OF  THE  GUMS. 

The  structural  changes  which  take  place  in  the  gums,  as  a  con- 
sequence of  increased  vascular  action,  are  almost  as  various  as  are  the 
constitutional  tendencies  of  different  individuals.  Those  characterizing 
the  aflPection  last  noticed  consist,  for  the  most  part,  in  increased  thick- 
ness and  recession  of  their  edges  from  the  necks  of  the  teeth  ;  but  in 
the  one  of  which  we  are  now  about  to  treat,  there  is  morbid  growth, 


INFLAMMATION   OF   THE   GUMS. 


213 


which  is  sometimes  so  considerable,  that  it  almost  covers  the  crowns 
of  the  teeth,  thus  interfering  very  seriously  with  the  function  of  masti- 
cation. When  thus  affected,  the  gums  have  a  dark  purple  color,  with 
thick,  smooth  and  rounded  margins ;  and  discharge  almost  constantly 
from  their  inner  surface  a  thin,  purulent  matter,  which  exhales  an  ex- 
ceedingly offensive  odor.  They  bleed  profusely  from  the  slightest  injury, 
and  are  so  sensitive  that  the  pressure  even  of  the  lips  is  sometimes 
attended  with  pain.  They  are  also  affected  with  a  peculiar  itching 
sensation,  which  at  times  is  a  source  of  great  annoyance. 

The  accompanying  engraving  (Fig.  78)  will  convey  to  the  reader  a 
more  correct  idea  of  the  appear- 
ance of  the  gums,  when  thus  Fig.  78. 
affected,  than  any  description 
which  can  be  given.  It  will  be 
perceived  from  this  that  the 
morbid  growth  extends  to  the 
gums  of  all  the  teeth,  as  it 
usually  does  in  this  variety  of 
diseased  action. 

Among  the  local  and  consti- 
tutional effects  arising  from  the 
disease  are  offensive  breath, 
vitiated   saliva,  destruction  of 

the  alveoli,  with  loosening  and  ultimate  loss  of  the  teeth,  impaired 
digestion,  with  all  its  disagreeable  concomitants,  enlargement  of 
the  tonsils,  and  bronchitis,  together  with  a  long  train  of  other 
phenomena. 

CAUSES. 

The  exciting  cause  of  this  peculiar  affection  is  local  irritation,  pro- 
duced by  salivary  calculus,  dead,  diseased,  or  irregularly  arranged 
teeth;  but  the  character  of  the  structural  alteration  is  evidently 
determined  by  some  cachectic  habit  of  body  or  constitutional  ten- 
dency. It^  often  attacks  the  gums  of  individuals  whose  teeth  are 
sound  and  well  arranged ;  but  the  author  has  never  met  with  a  case 
in  which  tartar  was  not  present;  though,  in  some  instances,  the 
quantity  was  so  small  as  almost  to  lead  one  to  doubt  whether  it  could 
have  had  much  agency  in  the  production  of  the  disease.  But  the 
susceptibility  of  the  gums  to  morbid  impressions  in  individuals  liable 
to  this  affection  is  usually  so  great,  that  an  irritant  which  under  other 
circumstances  would  scarcely  excite  an  increase  of  vascular  action, 
gives'rise,  in  cases  of  this  sort,  to  the  rapid  development  of  an  aggra- 
vated form  of  disease. 


214  DENTAL   PATHOLOGY,  THERAPEUTICS. 

TREATMENT. 

Tlie  first  thing  to  be  attended  to  in  the  treatment  of  the  disease  is 
the  removal  of  all  dead  teeth,  and  such  others  as  may  in  any  way 
irritate  the  gums.  The  morbid  growth  should  be  next  removed,  by 
making  a  horizontal  incision  entirely  through  the  diseased  gums  to 
the  crowns  of  the  teeth.  This  should  be  carried  so  far  back  as  the 
morbid  growth  extends.  After  this  the  gums  should  be  freely  scari- 
fied by  passing  a  lancet  between  the  teeth  down  to  the  alveoli,  in  order 
that  the  vessels  may  be  completely  divided,  and  discharge  their  accu- 
mulated blood.  This  should  be  repeated  several  times,  at  intervals 
of  four  or  five  days.  Meanwhile  the  mouth  may  be  washed  three  or 
four  times  a  day  with  some  astringent  and  detergent  lotion,  and  oc- 
casionally mopped  with  a  weak  solution  of  nitrate  of  silver.  Phenol 
Sodique — Phenate  of  Soda — either  in  its  full  strength  or  diluted  with 
from  one  to  twelve  times  its  bulk  of  water,  according  to  indications, 
proves  very  serviceable  as  a  lotion,  causing  the  rapid  absorption  of  the 
extravasated  blood,  preventing  fetor,  and  speedily  healing  and  harden- 
ing the  gums.  The  tartar  should  be  removed  as  soon  as  the  gums  have 
sufficiently  collapsed  to  admit  of  the  operation. 

The  progress  of  the  disease  may  be  arrested,  but  a  cure  cannot  be 
effected  by  local  treatment  alone.  Particular  attention  should  be  paid 
to  the  regimen  of  the  patient  and  such  general  remedies  prescribed  as 
the  peculiar  nature  of  the  case  may  indicate.  Excess  and  intemper- 
ance of  every  kind  must  be  avoided.  In  cases  of  an  inflammatory 
type,  the  diet  should  be  chiefly  vegetable ;  but  where  there  is  debility, 
or  other  cachexia,  animal  food  should  be  used,  taking  care  to  avoid  all 
young  meats,  as  veal  or  lamb,  all  gross  meats,  such  as  pork,  and  all 
salt  meats  or  shell-fish.  Fruits  and  acid  beverages,  such  as  infusions 
of  malt  and  vinegar,  lemon-juice,  spruce  beer,  etc.,  may  be_  used  with 
advantage. 

The  teeth  should  be  kept  perfectly  and  constantly  clean.  Not  a 
particle  of  foreign  matter  should  be  permitted  to  remain  between  them 
or  along  the  edges  of  the  gums.  A  scrupulous  attention  to  this  pre- 
caution is  indispensably  necessary,  as  it  constitutes  one  of  the  most 
important  remedial  indications. 

MERCURIAL   INFLAMMATION    OF    THE   GUMS. 

Small  and  repeated  doses  of  mercury,  w^hen  carried  to  the  point  of 
salivation,  frequently  give  rise  to  the  development  of  peculiar  morbid 
phenomena  in  the  gums  and  other  parts  of  the  mouth.  The  first 
indication  of  the  specific  action  of  this  powerful  medicinal  agent  upon 
the  animal  economy  consists  in  a  slightly  increased  redness  and  tume- 
faction of  the  free  edge  of  the  gums,  around  the  necks  of  the  inferior 


INFLAMMATION   OF   THE   GUMS.  215 

incisors.  There  is  a  characteristic  bluish  color  along  the  edge  of  the 
gums,  while  the  investing  mucous  membrane  of  the  adherent  portion, 
a  little  lower  down,  aften  assumes  a  white  color,  owing  to  the  opacity 
of  the  epithelium.  These  appearances  are  followed  by  increased 
secretion  of  saliva ;  a  strong  metallic  taste ;  soreness  of  the  teeth  and 
gums ;  inflammation  and  swelling  of  the  mucous  membrane  of  the  roof 
of  the  mouth,  fauces  and  cheeks,  and  the  salivary  glands ;  swelling  of 
the  tongue,  with  increased  redness  of  its  edges,  and  a  peculiarly  offen- 
sive odor  of  breath.  In  the  meantime,  the  edges  of  the  gums  about 
the  necks  of  the  teeth  swell  and  assume  an  increase  of  redness ;  the 
saliva  becomes  viscid,  and  is  secreted  in  such  abundance  as  to  flow  from 
the  mouth,  and  the  movements  of  the  jaws  are  attended  with  j)ain. 
The  alveolo-dental  periosteum  is  thickened,  and  the  teeth  raised  from 
their  sockets  and  loosened.  A  vesicular  eruption  sometimes  appears, 
followed  by  ulceration  and  sloughing  of  the  gums,  and  very  frequently 
by  necrosis  of  large  portions  of  the  alveolar  process  and  maxilla.  We 
were  shown,  a  few  years  since,  the  entire  alveolar  border  of  both  jaws, 
the  necrosis  and  exfoliation  of  which  had  been  occasioned  by  severe 
mercurial  salivation  ;  and  we  have  frequently  had  occasion  to  remove 
portions  both  of  the  superior  and  inferior  maxillary  bones — the  ne- 
crosis having  been  occasioned  by  the  use  of  this  medicine. 

By  the  prudent  administration  of  mercury,  salivation  may  be  in- 
duced, without  causing  the  deplorable  effects  just  described.  But  the 
specific  action  of  this  agent  upon  the  constitution  is  always  attended 
by  more  or-  less  tumefaction  and  sponginess  of  the  gums,  and  when 
once  brought  under  its  influence,  however  perfectly  its  effects  may 
have  subsided,  they  are  ever  after  more  susceptible  to  morbid  impres- 
sions. Again,  it  should  be  remembered  that  very  many  of  these  de- 
plorable symptoms  follow  the  use  of  mercurials,  even  where  there  is  no 
intention  to  salivate.  It  is  a  powerful  agent,  capable  of  much  good ; 
but  one  which  has  been  productive  of  untold  mischief,  especially  upon 
the  mouth  and  teeth.  Doubtless  life  must  be  saved  at  the  expense,  if 
necessary,  of  the  teeth.  But  the  peculiar  specific  action  of  this  medi- 
cine should  forbid  its  constant  and  indiscriminate  employment. 

TREATMENT. 

It  is  scarcely  necessary  to  say,  that  until  the  use  of  the  mercury  is 
discontinued,  it  will  be  impossible  to  control  or  even  counteract  its 
effects  upon  the  gums ;  but  in  mild  cases  these  usually  soon  disappear 
after  the  action  which  it  has  produced  on  the  general  system  has  com- 
pletely subsided.  When  the  gums  continue  spongy,  the  bowels  should 
be  kept  open  with  Seidlitz  powders  or  other  saline  cathartics,  the 
patient  restricted  to  a  fluid  farinaceous  diet,  and  the  mouth  gargled 


216  DENTAL  PATHOLOGY,  THERAPEUTICS. 

several  times  a  day  with  mild  astringent  lotions,  to  which  it  may  some- 
times be  advisable  to  add  a  little  laudanum.  Benefit  may  be  derived 
from  the  application  of  the  officinal  tincture  of  iodine  in  a  solution 
composed  of  one-half  water.  For  internal  use,  chlorate  of  potash 
and  iodide  of  potassium  are  considered  the  best  remedies  in  mercurial 
poisoning. 

The  chlorate  of  potash-  is  also  of  very  great  service  as  a  lotion,  in 
the  strength  of  one  drachm  to  the  ounce  of  water. 

For  internal  use,  ten  grains  of  the  chlorate  of  potash  may  be  dis- 
solved in  half  an  ounce  of  water,  and  administered  in  four  or  five  doses 
during  the  day.  For  an  adult,  Dr.  Garretson  recommends  the  following 
lotion  as  very  beneficial,  in  cases  where  the  tumefaction  is  very  great 
and  indolent  looking : — 

B.     Potassae  cMoras ^ss 

Sodse  boras, 

Alumen  pulv aa ^ij 

Potass,  permang grs.  xxv 

Aqua  cologn ,^ss 

Tinct.  cinchonae ^ij 

Tinct.  myrrhae ^j 

Infus.  quercus  (fort. ) ^  iv.  M. 

SiG. — Gargle  the  mouth  pro  re  nata. 

The  iodide  of  potassium  may  be  given  in  doses  of  from  three  to  five 
grains,  three  times  a  day,  in  some  bitter  infusion. 

The  following  gargle  will  be  found  very  serviceable  in  mercurial 
salivation : — 

B.     Tinct.  iodinii ^iij  to  vj 

Potassae  iodidi grs.  xvtoxxx 

Aquae Oss.  M. 

After  the  action  of  the  medicine  upon  the  system  has  subsided,  and 
the  disease  assumes  a  chronic  form,  the  gums,  as  directed  by  Mr. 
Thomas  Bell,  should  be  freely  scarified  by  passing  a  lancet  entirely 
through  their  substance,  between  the  teeth  ;  and  this  operation  should 
be  repeated  as  often  as  every  few  days,  until  they  are  completely 
restored.  The  use  of  astringent  washes  should  at  the  same  time  be 
continued,  and  if  there  are  any  teeth  which,  from  the  loss  of  their 
vitality,  or  from  having  become  very  much  loosened  by  the  partial 
destruction  of  their  sockets,  act  as  irritants,  they  should  be  removed. 

For  correcting  the  fetor  arising  from  the  ulcerated  surfaces,  a  gargle 
may  be  used  composed  of  two  or  three  drachms  of  charcoal  suspended 
by  agitation  in  a  tumbler  of  water.  After  retaining  a  portion  of  this 
gargle  for  a  short  time,  the  mouth  should  be  rinsed  with  warm  water, 
to  remove  the  particles  of  charcoal. 


INFLAMMATION   OP   THE   GUMS.  217 

A  solution  of  the  permanganate  of  potash,  in  the  strength  of  from  two 
to  ten  grains  to  the  ounce  of  water,  is  also  highly  recommended  as  a 
p-aro-le  for  the  removal  of  the  fetor  ;  also  washes  made  from  chlorinated 
soda  or  lime. 

ULCERATION    OF   THE   GUMS   OF    CHILDREN   ATTENDED   WITH    EXFOLI- 
ATION  OF   THE    ALVEOLAR    PROCESSES. 

The  gums  and  alveolar  processes  of  children  are  occasionally  at- 
tacked by  a  very  peculiar  form  of  disease,  which  occurs  more  fre- 
quently during  the  shedding  of  the  temporary  and  the  eruption  of 
the  permanent  teeth  than  at  any  other  period  of  childhood.  We  have 
never  known  adults  to  be  affected  with  it,  and  to  the  ordinary  spongy, 
inflamed  and  ulcerated  gums  it  does  not  appear  to  be  at  all  analogous. 
It  bears  a  much  closer  resemblance  to  cancrum  oris,  yet  differs  in  many 
particulars  from  this  disease. 

Among  the  symptoms  which  characterize  the  affection,  are  itching 
and  ulceration  of  the  gums  and  their  separation  from  the  necks  of  the 
teeth  and  alveolar  processes ;  there  is,  at  first,  a  discharge  of  muco- 
purulent matter  from  between  the  gums  and  necks  of  the  teeth,  which 
ultimately  becomes  ichorous  and  fetid.  The  teeth  loosen,  and  the 
alveoli  lose  their  vitality  and  exfoliate.  Ulcers  are  formed  in  various 
parts  of  the  mouth,  and  the  gums  and  lips  assume  a  deep  red  or  purple 
color.  In  the  exfoliation  of  the  alveolar  processes,  the  temporary,  and 
sometimes  the  crowns  of  the  permanent  teeth,  are  carried  away.  The 
constitutional  symptoms  are  :  skin,  for  the  most  part,  dry  ;  pulse,  small 
and  quick ;  the  bowels  generally  constipated,  though  sometimes  there 
is  diarrhoea  ;  and  to  these  symptoms  may  be  added  lassitude  and  a  dis- 
position to  sleep. 

These  may  be  regarded  as  the  prominent  phenomena  of  the  disease 
in  its  most  aggravated  form.  When  exfoliation  of  the  alveolar  pro- 
cesses takes  place,  the  symptoms  usually  abate,  and  sometimes  wholly 
disappear.  Delabarre  says  :  "  Among  the  great  number  of  children 
that  are  brought  to  the  orphan  asylum,  he  has  had  frequent  occasion 
to  notice  singular  complications  of  the  affection,  as  modified  by  the 
strength,  sex  and  idiosyncrasies  of  the  different  subjects."  The  gums 
and  lips,  in  some,  he  describes  as  being  of  a  beautiful  red  color ;  in 
others,  the  lips  are  rosy  and  the  gums  pale,  and  sometimes  very  much 
swollen.  He  also  enumerates  among  the  symptoms,  burning  pain  in 
the  mucous  membrane  of  the  cheeks,  and  ulceration,  pain  and  swell- 
ing in  the  submaxillary  glands. 

In  the  majority  of  cases  the  disease  is  confined  to  one  jaw  and  to 
one  side,  though  sometimes  both  are  aflfected  by  it.  The  effect  on  the 
permanent  teeth,  in  all  the  cases  which  have  fallen  under  the  notice 


218  -  DEXTAL  PATHOLOGY,  THERAPEUTICS. 

of  the  author,  was  injurious,  though  Delabarre  says  that  in  children 
who  have  reached  their  seventh  or  eighth  year  the  teeth  are  not  in- 
jured, except  that  they  may  be  badly  arranged,  in  consequence  of  the 
want  of  a  proper  development  of  the  jaw. 

The  author  enumerates  the  following  symptoms  of  a  very  aggravated 
form  of  this  disease  :  inordinate  appetite,  burning  thirst,  a  small  spot 
on  the  cheek,  or  about  the  lips,  resembling  an  anthrax,  which  rapidly 
increases  in  size,  turns  black,  separates,  discharges  an  ichorous  fluid, 
and  its  edges  roll  themselves  up  like  flesh  exposed  to  the  action  of  a 
brisk  fire  ;  the  flesh  separates  from  the  face,  the  bones  become  exposed, 
hectic  fever  ensues,  and  in  the  course  of  fifteen  or  twenty  days  death 
puts  an  end  to  the  sufferings  of  the  child.  Delabarre  asserts  that  this 
affection  is  more  common  among  females  than  males,  and  that  the 
bones  of  the  jaw  are  so  much  softened  that  they  may  be  easily  cut 
with  a  knife. 

CAUSES. 

The  disease  seems  to  be  the  result  of  general  debility  or  defective 
nutrition  and  a  cachectic  habit  of  body.  It  appears  to  be  almost 
wholly  confined  to  children  of  the  poor  and  destitute,  and,  so  far  as  the 
author's  observations  extend,  to  those  who  reside  in  cellars  or  small  and 
confined  apartments.  Children  of  scorbutic  habit  seem  to  be  the  most 
subject  to  it.  From  the  great  debility  of  all  the  organs  of  the  body,  their 
functions  are  languidly  and  imperfectly  performed.  That  the  disease  is 
determined  by  general  enfeeblement  of  the  functions  of  the  body,  there 
is,  we  think,  little  doubt ;  but  whether  it  would  develop  itself  indepen- 
dently of  any  local  cause,  is  a  question  which  we  do  not  feel  ourselves 
able  satisfactorily  to  answer.  It  is  not  at  all  improbable  that  local  irri- 
tants are  the  exciting  cause ;  and  we  are  the  more  inclined  to  this  be- 
lief from  the  fact  that  in  all  the  cases  which  have  fallen  under  our 
observation  the  teeth  were  considerably  decayed,  and  had  previously 
given  rise  to  pain  ;  and  in  some  instances  they  were  coated  with  tartar. 
While,  therefore,  the  character  of  the  affection  is  determined  by  some 
peculiar  constitutional  tendency  and  general  enfeeblement  of  the  vital 
powers  of  the  body,  it  is  not  unlikely  that  local  irritation  is  the  imme- 
diate cause  of  its  development. 

TREATMENT. 

As  the  treatment  of  this  affection  comes  more  immediately  within 
the  province  of  the  medical  than  of  the  dental  practitioner,  we  shall 
not  dwell  long  upon  the  subject. 

The  local  treatment  should  consist  of  acidulated  and  astringent 
gargles,  and  a  chlorinated  solution  of  lime  or  soda.  The  ulcerated 
parts  may  be  occasionally  touched  with  a  strong  solution  of  the  nitrate 


INFLAMMATION   OF   THE   GUMS.  219 

of  silver,  and  Delabarre  says  he  has  in  some  cases  derived  great  ad- 
vantage from  touching  them  with  the  actual  cautery.  As  soon  as  the 
alveolar  process  exfoliates,  it  should  be  removed.  After  this  takes 
place,  a  cure  is  generally  speedily  effected  under  proper  constitutional 
treatment.  This  last  may  consist  of  mild  alteratives,  a  generous  nu- 
tritive diet,  consisting  of  succulent  vegetables,  and,  in  the  absence  of 
fever,  of  wholesome  meats,  tonics,  and  exercise  in  the  open  air.  (See 
"  Ulcerous  Stomatitis.") 

ALVEOLAR   PYOREHCEA. 

Alveolar  Pyorrhoea,  commonly  designated  "  Riggs'  disease,"  denotes 
suppurative  inflammation  of  the  gums,  attended  with  the  destruction 
of  the  alveolar  processes.  It  usually  commences  with  an  uneasy 
sensation  in  the  gums  and  teeth,  which  soon  become  painful. 

At  an  early  stage  of  this  disease  the  margin  of  the  gum  presents 
decided  inflammatory  action,  and  bleeds  from  slight  causes. 

'As  the  disease  progresses,  the  inflammation  extends  deeper  into  the 
substance  of  the  gum,  which  becomes  greatly  congested  with  venous 
blood,  swollen,  and  exhibits  a  tendency  to  separate  from  the  necks  of 
the  teeth,  which  gives  rise  to  the  formation  of  small  sulci  filled  with 
pus.  There  is  also  a  loss  of  substance  of  the  gum,  and  the  destruction 
of  the  margins  of  the  alveolar  processes  is  followed  by  the  death  of 
the  thicker  portions  beneath,  and,  as  a  consequence,  the  teeth  become 
loose  and  change  their  positions.  There  is  frequently  a  separation  and 
protrusion  of  the  superior  and  inferior  front  teeth,  with  a  thick,  fetid 
discharge  from  about  their  necks,  which  causes  a  disagreeable  taste 
and  a  very  offensive  breath.  The  gum  at  this  stage  of  the  disease,  is 
of  a  dark  purple  or  livid  hue,  with  a  congested  margin,  and  in  some 
cases,  on  account  of  its  being  denuded  of  its  epithelium,  its  surface 
presents  a  polished  appearance ;  it  may  also  become  granular,  and 
covered  with  fungous  excrescences.  At  an  extreme  stage  of  the  dis- 
ease, complete  destruction  of  the  alveoli,  and  of  a  considerable  portion 
of  the  gum  occurs,  and  the  teeth  are  held  in  place  by  a  tough,  liga- 
mentous attachment,  which  was  formerly  the  alveolo-dental  periosteum. 
The  roots  of  the  teeth  become  coated  with  a  layer  of  calculus,  of  a 
greenish-brown  color  and  great  hardness,  which  adheres  tenaciously, 
rendering  its  removal  very  difficult. 

The  congestion  and  consequent  recession  of  the  gum  from  about  the 
necks  of  the  teeth,  permits  the  calculus  to  form  on  the  roots,  by  the 
ready  access  afforded  to  the  fluids  of  the  mouth. 

The  nature  of  the  calculous  deposit  is  no  doubt  modified  by  the  acid 
mucus  from  the  gum. 


220  DENTAL   PATHOLOGY,  THERAPEUTICS. 

CAUSES. 

Although  alveolar  pyorrhoea  is  a  disease  depending  almost  wholly 
upon  local  causes,  such  as  the  irritation  of  salivary  calculus,  yet  its 
peculiar  manifestation,  no  doubt  often  depends  upon  some  unfavorable 
diathesis,  which  enables  the  local  causes  to  produce  more  serious  effects 
than  might  be  possible  in  better  systemic  conditions.  If  the  teeth  are 
perfectly  free  from  irritating  accretions,  and  present  smooth,  polished 
surfaces,  at  points  where  the  more  highly  vitalized  surrounding  struc- 
tures come  in  contact  with  them,  no  inflammatory  action  will  occur  in 
such  structures.  On  the  other  hand,  if  the  teeth,  on  account  of  sali- 
vary and  other  deposits  about  the  margin  of  the  gum  and  along  their 
roots,  act  as  irritants,  inflammatory  action,  followed  by  such  effects  as 
the  disease  under  consideration  presents,  may  ensue. 

TREATMENT. 

In  the  early  stage  of  alveolar  pyorrhoea  all  salivary  deposition 
should  be  carefully  removed,  and  the  surfaces  beneath  well  polished  ; 
a  decided  change  for  the  better  may  occur  in  a  very  short  time,  as  the 
inflamed  gum  will  lose  its  congested  appearance,  and  assume  a  lighter 
color  and  a  firmer  consistence,  and  become  reduced  to  its  normal 
thickness.  In  the  more  advanced  stages  of  this  disease,  the  treatment 
consists  in  reaching,  by  means  of  narrow,  sharp  instruments,  the  ex- 
treme limits  of  the  diseased  action,  removing  all  deposits,  and  breaking 
up  the  diseased  tissue  and  necrosed  bone,  and  polishing  the  surfaces 
roughened  by  depositions  of  calculus. 

A  nice  sense  of  touch,  only  acquired  by  practice,  will  enable  the 
operator  to  distinguish,  with  the  instrument,  foreign  and  dead  sub- 
stance from  tooth  structure  and  living  bone.  It  is  especially  necessary 
that  every  particle  of  salivary  calculus  and  necrosed  bone  should  be 
removed,  as  their  presence  will  be  indicated  by  a  reddened  patch  of 
tissue,  somewhat  larger  than  the  irritant  beneath.  As  the  removal  of 
such  irritants  causes  both  pain  and  hemorrhage,  such  an  operation  will 
require  several  sittings,  and  the  frequent  application  of  carbolic  acid, 
by  means  of  a  properly  shaped  piece  of  orange  wood.  After  this 
operation  is  completed  an  application  of  dilute  aromatic  sulphuric  acid 
will  prove  serviceable.  The  effect  of  such  treatment  is  to  promote  the 
reproduction  of  new  bone,  and  cause  the  gum  to  become  firmly  attached 
to  it,  and  thus  restore  the  stability  of  the  teeth,  and  in  many  cases  the 
only  therapeutic  treatment  necessary  will  be  the  use  of  an  astringent 
wash,  such  as  tincture  of  myrrh  in  its  full  strength,  applied  to  the  gum 
about  the  necks  of  the  teeth.  When  constitutional  disturbance, exists 
in  connection  with  the  local  effects,  after  perfectly  removing  all  irri- 
tants, a  dilute  solution  of  chloride  of  zinc  may  be  applied  to  the  ulcer- 


INFLAMMATION   OF   THE   GUMS. 


221 


ating  surfaces  by  passing  it  under  the  gum,  about  the  necks  and  roots 
of  the  teeth,  by  means  of  cotton  wound  on  a  broach,  and  alternating 
with  dilute  aromatic  sulphuric  acid,  and  tincture  of  iodine  applied  to 
the  surface  of  the  gum.  Chlorate  of  potash  solution  should  be  used 
as  a  mouth-wash  after  each  meal  and  at  night,  with  as  thorough  use 
of  the  brush  as  the  condition  of  the  gums  will  permit.  The  use  of  a 
solution  of  common  salt  is  recommended  during  the  intervals  between 
the  applications  of  the  more  powerful  remedies ;  also  phenol  sodique. 

For  the  worst  stage  of  this  disease,  where  the  teeth  are  held  in  the 
mouth  by  means  of  the  tough,  ligamentous  attachments  only,  their 
removal  is  inevitable. 

The  following  illustration  represents  Dr.  J.  M.  Riggs'  set  of  instru- 
ments for  the  thorough  removal  of  all  salivary,  sanguinary,  and  other 
deposits  from  the  roots  of  the  teeth,  in  the  treatment  of  this  disease. 

Fig.  79 


A  method  of  treatment  recently  recommended  by  Dr.  A.  W.  Har- 
lan, is  as  follows :  For  the  acute  form,  the  pockets  formed  by  the  sepa- 
ration of  the  gum  should  be  first  filled  with  iodoform  and  eucalyptus, 
iodoform  and  oil  of  cinnamon,  or  be  thoroughly  syringed  with  a  one 
to  three-grain  solution  to  the  ounce  of  water,  of  chloride  of  alumina, 
which  is  a  good  disinfectant  and  astringent.  In  three  or  four  days  the 
sanguinary  deposits  may  be  removed,  as  well  as  the  edges  of  the  alveoli. 
The  pockets  should  then  be  syringed  with  peroxide  of  hydrogen,  for 
the  purpose  of  thoroughly  cleansing  them  and  also  to  destroy  the 
micro-organisms  present.  After  drying  the  gums,  the  pockets  should 
be  injected  with  a  solution  of  iodide  of  zinc,  grs.  xii  to  grs.  xiv,  to  the 
ounce  of  water,  two  or  three  drops  or  more  to  each  pocket.  After 
several  days  have  elapsed,  the  gums  should  be  carefully  dried,  and 
a  fine  cone  of  cotton  or  bibulous  paper  moistened  with  peroxide  of 
hydrogen  gently  pressed  into  each  pocket ;  if  any  pus  is  present  efl^er- 
vescence  will  take  place,  when  each  pocket  must  be  again  injected 


222  DENTAL  PATHOLOGY,  THEEAPEUTICS. 

with  the  iodide  of  zinc  solution.  In  chronic  cases,  after  the  removal 
of  the  diseased  bone,  and  the  careful  cleansing  of  the  roots,  the  pockets 
should  be  syringed  with  peroxide  of  hydrogen,  followed  by  the  injec- 
tion of  a  xxiv  gr.  solution  of  the  iodide  of  zinc,  in  the  same  manner 
as  before  described.  In  very  bad  cases,  a  stronger  solution  of  the 
iodide  of  zinc  is  recommended,  xxviii  grs.  to  the  ounce  of  water ;  and 
when  the  margins  of  the  gums  present  a  ragged  border  or  cone-shaped 
slit,  pure  granular  iodide  of  zinc  is  applied  to  the  edges  of  the  slit 
once  in  three  days,  the  injection  into  the  pockets  being  repeated  every 
fourth  day. 

ADHESION   OF   THE   GUMS   TO   THE   CHEEKS. 

The  gums  and  inner  walls  of  the  cheeks  sometimes  contract  adhe- 
sions which  interfere  seriously  with  the  functions  of  the  mouth.  The 
affection  may  be  congenital,  but  in  the  majority  of  cases  it  occurs 
subsequently  to  birth.  The  extent  of  the  adhesion  may  be  small,  or  it 
may  occupy  the  gums  of  the  entire  alveolar  border  of  one  or  both  sides 
of  the  mouth,  and  of  one  or  both  jaws.  Desirabode  relates  the  case  of 
a  young  man,  who,  in  consequence  of  a  venereal  ulcer,  had  his  upper 
lip  united  to  the  gums  of  the  four  incisors  in  such  a  way  as  to  form  a 
sort  of  loop  above  the  teeth,  which,  by  the  retraction  of  the  lip,  were 
caused  to  project  outward.* 

Adhesion  of  the  gums  to  the  cheek  or  lips  results  from  ulceration, 
caused  either  by  constitutional  disease  or  local  lesions.  But  that  it 
arises  more  frequently  as  a  consequence  of  the  immoderate  use  of 
mercury  than  from  any  other  cause,  is  a  universally  admitted  fact. 
The  author  has  met  with  several  cases,  however,  in  which  the  affection 
has  resulted  from  ulceration  of  the  gums  around  necrosed  temporary 
teeth,  and  of  the  corresponding  wall  of  the  cheek,  caused  by  excoria- 
tion of  the  mucous  membrane,  produced  by  the  sharp  points  of  the 
protruding  roots.  But  the  extent  of  the  adhesion,  in  cases  of  this  sort, 
is  never  very  considerable. 

The  proper  remedy  is  to  separate  the  parts  which  have  grown  to- 
gether with  a  sharp  bistoury.  This  done,  reunion  should  be  prevented 
by  keeping  a  pledget  of  cotton  or  lint  in  the  wound,  until  the  process 
of  cicatrization  is  completed. 

*  Authors  translation  of  Desirabode" s  "  Complete  Elements  of  Science  and 
Art  of  the  Dentist,"  p.  227. 


TUMORS   OF   THE   MOUTH   AND   JAWS.  223 


CHAPTER  V. 

TUMORS  OF  THE  MOUTH  AND  JAWS. 

TUMORS  of  the  gums  are  of  various  kinds ;  some  interesting  cases  of 
simple  hypertrophy  are  reported  by  Dr.  Gross  and  Mr.  Salter  and 
Mr.  Erichsen,  which  are  reproduced  by  Mr.  Heath  in  his  admirable 
"  Essay."  Mr.  Salter's  case  was  found  to  consist  of  a  pinkish,  corru- 
gated and  lobed  mass,  composed  of  an  expansion  of  the  alveolus,  with 
"  immense  hypertrophy  of  the  fibrous  gum,  and  an  exuberant  growth  of 
the  papillse  of  the  mucous  membrane."  Dr.  Gross's  case  was  somewhat 
similar.  Mr.  Erichsen's  was  found,  "  on  section,  to  consist  of  firm, 
fibrous  stroma,  containing  much  glandular  tissue  in  its  interstices,  and 
covered  on  its  surface  by  very  large  and  vascular  papillse.  The  epi- 
thelial layer  was  of  unusual  thickness,  but  no  abnormal  epithelial 
structures  were  found  in  the  growth,  which  was  an  example  of  true 
hypertrophy."     (Heath's  "  Jacksonian  Essay,"  190.) 

A  peculiarity  of  this  case  was  that  the  teeth  were  also  hypertrophied. 
In  each  of  these  cases  the  diseased  tissue  was  removed  and  the  exposed 
surface  cauterized. 

Polypus  is  a  simple  hypertrophy  of  the  interdental  gum,  or  dental 
pulp,  and  is  generally  occasioned  by  the  irritation  of  a  worn-out  or 
broken  tooth  with  a  ragged  edge.  In  structure  these  growths  are  like  the 
gum  from  which  they  arise.  They  seldom  give  much  pain,  except  ulcer- 
ation should  take  place.  If  simply  cut  away,  they  are  very  likely  to 
return  ;  but- if  the  tooth  is  removed,  and  astringent  or  cauterant  appli- 
cations be  made,  they  give  but  little  trouble. 

Continuous  pressure,  by  gutta  percha  or  other  means,  will  also  con- 
trol them. 

Mr.  Salter  reports  two  cases  of  "  Papillary  Tumors  of  the  Gums," 
consisting  almost  entirely  of  epithelium,  arranged  in  filiform  papillse 
resembling  those  of  the  tongue.  It  is  described  as  "  a  curious  white 
mass,  consisting  of  coarse,  detached  fibres,  pointed  and  free  at  one  ex- 
tremity and  attached  at  the  other  ;  in  fact,  it  was  a  mass  of  papillse, 
many  of  them  nearly  an  inch  long,  and  similar  in  shape  to  the  '  filiform ' 
papillse  of  the  tongue  ;  their  surface  was  shreddy  and  broken  ;  among 
the  elongated  processes  were  a  few  rounded  eminences  like  '  fungiform  ' 
papillse,  and  these  had  a  smooth  and  broken  surface." 

The  term  Epulis  is  usually  applied  to  tumors  springing  from  the 
margin  of  the  gums,  whatever  their  structural  character.     They  most 


224 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


Fig.  80. 


commonly  spring  from  the  gum,  between  two  teeth  ;  as  they  continue 
to  grow,  the  base  may  increase  also  in  size,  till  it  covers  the  alveolar 
bone,  or  it  may  undergo  superficial  development,  the  point  of  attach- 
ment undergoing  but  little  change ;  in  other  words,  it  may  possess  a 
broad,  flattened  base  or  a  narrow  pedicle.  In  structure  it  bears  a 
close  resemblance  to  the  gum,  and  sometimes  has  imbedded  in  it  spi- 
culse  of  bone,  which  may  have  been  detached  from  the  alveolar  bone, 
constituting  the  source  of  irritation  which  gave  rise  to  the  morbid 
growth ;  or  it  may  have  been  a  true  osseous  development ;  a  portion  of 
germinal  matter,  having  escaped  from  its  true  osseous  relation,  has 
been  here  arrested,  established  a  false  centre  of  growth,  and  undergone 
development,  in  obedience  to  the  primitive  impulse  of  the  parent  cell 
from  which  it  was  derived. 

The  accompanying  figure,  from  Mr.  Heath,  is  a  typical  epulis  of  the 

most  common  variety.  It  is  seen  to 
be  a  "  firm,  fibrous  tumor,"  with  "some 
fibro-plastic  cells  intermingled."  This 
variety  of  epulis  is  not  unusually  at- 
tached to  the  periosteum  of  the  alve- 
olus, with  projecting  spiculse  of  bone 
entering  it  from  the  maxilla. 

Left  to  themselves,  these  tumors  will 
often  continue  to  grow,  encroaching 
upon  the  tongue,  hard  palate,  and 
teeth.  They  are  thus  made  liable  to 
injury  by  the  teeth,  and  an  ulcerated  surface  is  in  this  way  established, 
which  discharges  freely,  occasions  considerable  pain,  and  may  become 
the  seat  of  hemorrhage. 

A  softer  and  more  vascular  variety  is  described  by  Mr.  Hutchin- 
son as  consisting  of  fibrous  tissue,  in  which  are  imbedded  a  large 
number  of  polynucleated  cells  of  the  myeloid  variety.  In  the 
"  Transactions  of  the  Pathological  Society,"  he  thus  describes  them : 
"  The  epulis  presented  all  the  characters  of  myeloid  growth  in 
a  most  remarkable  degree.  Its  section  was  very  vascular,  and 
showed  hues  varying  from  a  deep  red  to  bufi",  and  a  peculiar 
light-greenish  tint  of  yellow  (xanthoid  of  Lebert).  Scattered  in 
its  structures  were  some  detached  masses  of  soft,  spongy  bone. 
Under  the  microscope  were  seen  an  abundance  of  the  large  poly- 
nucleated bodies  characteristic  of  these  growths,  many  of  them 
being  very  irregular  in  shape  and  much  branched."  This  form  of 
epulis  is  most  frequently  connected  with  the  interior  of  the  alveolus, 
and  heuce  more  closely  resembles  the  endosteal  structures.  When 
presenting   an    ill-conditioned   and    ulcerated    surface,  it   closely   re- 


(FiG.  90  of  "  Heath  on  the  Jaws.") 


TUMORS   OF   THE   MOUTH    AND   JAWS.  225 

sembles  a  malignant  growth,  but  does  not,  as  has  been  thought  by 
some  writers,  pass  into  cancer. 

Mr.  Heath  also  describes  a  variety  which  he  calls  "  Giant-celled 
Epulis,"  consisting  of  "  large,  irregular,  disc-like  cells  containing  nu- 
merous beard-like  nuclei  interspersed  among  the  fibrous  tissue."  It 
presents  a  surface  of  uniform  smoothness,  of  a  dark-gray  color,  with 
numerous  purple  spots  upon  it.  He  considers  it  as  holding  a  position 
intermediate  between  "  fibro-cellular  and  myeloid  tumors,"  and  of  a 
similar  nature  to  the  growths  described  by  Otto  Weber  as  "  giant-celled 
sarcoma,"  and  as  a  "  fibrous  form  of  cancer  arising  from  bone,"  by 
Wedl. 

Another  form  of  epulis,  resembling  epithelioma,  and  of  interest,  as 
showing  that  epithelioma  may  be  developed  in  the  gum  as  elsewhere, 
is  thus  described  in  a  report  by  Mr.  Bruce  to  Mr.  Heath  : — 

"  The  surface  of  the  tumor  is  covered  with  healthy  mucous  mem- 
brane. The  interior  of  the  tumor  is  whiter,  firmer,  and  more  compact 
than  the  surface,  but  there  is  no  line  of  demarcation  between  the  tumor 
and  its  mucous  covering.  The  structure  of  the  growth  is  distinctly 
glandular,  very  much  resembling  some  form  of  compact  adenoid  tumor 
of  the  breast. 

"  At  the  point  of  attachment  of  the  tumor  to  the  parts  beneath,  a 
remarkable  transformation  of  the  glandular  into  the  epitheliomatous 
structure  is  seen.  In  one  part  of  the  section  may  be  seen  the  cut  ends 
of  gland  tubules,  whilst  in  their  immediate  neighborhood  are  most  dis- 
tinct nests  of  true  epithelioma,  consisting  evidently  of  concentrically 
arranged  cells  compressed  from  the  centre  upward." 

Mr.  Adams  reports  a  similar  case  which  resulted  in  death,  the  dis- 
ease having  reappeared  in  the  skin  after  its  removal. 

It  is  often  difficult  to  determine  the  causation  of  epulis,  but  they 
may  often  be  referred  to  the  irritation  of  broken  or  unsound  teeth,  or 
to  fragments  of  the  alveolar  bone  which  become  detached,  or  to  out- 
growths from  the  alveolus ;  most  frequently,  however,  to  roots  of 
decayed  teeth ;  hence  Mr.  Heath  thinks  the  greater  frequency  of  these 
tumors  in  women — five  to  three — they,  having  a  greater  dread  of  all 
surgical  operations,  are  more  likely  to  permit  useless  roots  to  remain 
in  their  mouths. 

It  is  rarely  fatal,  but  sometimes  attains  such  size  as  to  produce  great 
deformity,  pain,  and  embarrassment  of  the  functions  of  mastication 
and  deglutition. 

For  the  treatment  of  epulis,  nothing  short  of  the  entire  removal  of 
the  tumor,  with  its  periosteal  attachments,  together  with  all  decayed 
teeth,  or  even  sound  ones — when  the  disease  seems  inclined  to  repro- 
duce  itself — promises   any   good   result.     After   excision,  the  actual 
15 


226  DENTAL   PATHOLOGY,  THERAPEUTICS. 

cautery  should  be  freely  applied,  for  the  double  purpose  of  destroying 
all  trace  of  the  disease  and  of  arresting  hemorrhage. 

Tumors  of  the  hard  palate  are  closely  related  to  epulis,  and  papil- 
lary and  epithelial  forms  are  reported — the  former  presenting  but  little 
difterence  from  tumors  of  the  same  character  arising  on  the  gum. 

An  epithelial  tumor  occurring  on  the  hard  palate  is  reported  by  Dr. 
Andrew  Clark,  which  was  described  as  "soft,  elastic  and  vascular. 
The  cut  surface  is  of  a  dead-white  color,  distinctly  granular,  like  rough 
honey,  crumbly-looking,  and  studded  with  red  or  pink  blotched  parts 
sunk  below  the  general  level.  On  further  examination,  it  appears 
to  be  permeated  by  a  kind  of  glairy  substance  (colloid  matter),  which 
helps,  seemingly,  to  give  coherence  to  the  tumor.  To  the  naked  eye 
the  tumor  resembles  in  some  respects  a  cephaloid  or  myeloid  mass.  To 
the  latter  it  bears  the  greatest  resemblance  in  general  character,  seat 
and  structure.  The  microscopic  characters  are  those  of  epithelial 
cancer,  epithelial  cells  in  all  stages  of  development  and  of  the  most 
various  forms,  together  with  a  few  nest-cells  and  fat.  The  mucous 
membrane  over  the  tumor,  though  not  continuous  with  it,  presents  the 
same  structural  characters.  This  decides  the  doubt  between  the  epi- 
thelioma and  myeloma."     (Heath's  "  Jacksonian  Essay,"  p.  208.) 

Encysted  tumors  of  the  hard  palate  are  also  sometimes  found,  but 
they  are  rare,  and  require  no  special  description  in  a  work  of  this 
character. 

These  tumors,  when  epuloid  in  character,  are  to  be  treated  in  the 
manner  already  described.  When  the  bone  becomes  affected,  it  also 
must  be  removed  to  such  an  extent  as  will  leave  an  entirely  healthy 
surface. 

Unerupted  teeth  may  also  give  rise  to  osseous  tumors,  requiring  sur- 
gical interference.  This  is  more  peculiarly  the  case  with  the  wisdom 
tooth,  for  a  reason  easily  understood:  the  space  nominally  allotted  it, 
betAveen  the  second  molar  and  the  terminal  point  of  the  alveolar  ridge, 
is  often  too  limited  for  its  eruption ;  endeavoring  to  make  its  way 
through  the  bone,  under  such  circumstances,  the  opposition  it  encoun- 
ters is  often  sufficient  to  occasion  great  irritation  and  pain,  and  occa- 
sionally to  entirely  prevent  its  eruption.  The  retained  tooth  thus 
becomes  a  centre  of  irritative  action,  and  may  serve,  not  only  to 
determine  the  site,  but  the  fact  of  such  tumors.  Mr.  Tomes  also  re- 
lates a  case  in  which  the  wisdom  tooth  was  bound  down  by  a  "  mass  of 
enamel,  dentine  and  cementum,  thrown  together  without  any  definite 
arrangement,"  which  occupied  the  place  of  the  second  molar.  Mr. 
Heath  also  records  a  case,  reported  by  Dr.  Forget,  in  Avhich  a  tumor 
about  the  "consistence  of  ivory,"  covered  everywhere  with  enamel, 
and  about  the  size  of  an  egg,  occu^ned  that  portion  of  the  jaw  between 


TUMORS   OF  THE   MOUTH   AND   JAWS.  227 

the  ramus  and  the  first  bicuspid.  It  was  composed  chiefly  of  enamel 
and  dentine,  with  portions  of  cementum  "dipping  into  the  crevices" 
here  and  there,  and  was  regarded  by  Dr.  Forget  as  a  "  fusion  and 
hypertrophy  of  the  last  two  molars." 

Again,  one  of  the  anatomical  elements  of  the  tooth  may  become 
so  hypertrophied  as  to  constitute  a  troublesome  disease,  and  call  for 
surgical  interference.  The  cementum  is  most  likely  to  undergo  such 
change.  M.  Maisonneuve  reports  a  case,  cited  by  Mr.  Heath,  in 
which  the  hypertrophied  cementum  attained  the  size  of  a  pigeon's 
egg- 
It  is  desirable,  if  possible,  to  remove  all  such  morbid  growths  with- 
out injury  to  the  bone  in  which  they  are  implanted ;  but  it  may 
become  necessary  to  excise  that  part  of  the  jaw  in  which  it  is.  All 
neighboring  teeth  which  may  possibly  be  associated  with  it  should  be 
removed. 

Tumors  of  the  antrum  and  upper  jaw  may  be  appropriately  de- 
scribed together,  the  distinguishing  characteristics  being  pointed  out. 

Polypus. — Growths  of  this  character  occasionally  occur  in  the 
antrum,  and  are  closely  allied  to  the  small  cysts  occurring  in  its 
mucous  membrane ;  both  are  essentially  a  "  hypertrophy  of  some  ele- 
ment of  the  mucous  or  sub-mucous  tissue.  When  the  connective  or 
areolar  tissue  predominates,  the  fleshy  polypus  is  produced  ;  when  the 
glandular  element  is  especially  affected,  we  have  the  cystic  form  pro- 
duced. Intermediately,  when  the  fibrous  element  is  very  loose,  and  we 
have  some  glandular  hypertrophy,  the  semi-gelatinous  polypus  is  pro- 
duced, which  closely  resembles  the  nasal  polypus."  ("  Jacksonian 
Essay,"  p.  210.)  . 

Antral  jDolyps  are  very  vascular,  and  are  sometimes  the  ushers  of 
malignant  disease.  The  diagnosis  is  exceedingly  diffieult  until  they 
have  advanced  sufficiently  to  break  down  the  osseous  wall  somewhere ; 
this  most  frequently  takes  place  into  the  nose,  through  the  thin  nasal 
wall. 

They  should-  be  removed  as  soon  as  ascertained  to  exist,  and  the 
troublesome  hemorrhage  which  is  likely  to  occur  should  be  arrested 
by  injections  of  a  reliable  styptic  in  any  strength  which  is  not  likely 
to  give  rise  to  trouble,  if  the  opening  is  sufficiently  large  to  permit 
its  ready  escape. 

A  single  instance  of  a  peculiar  form  of  fibroid  growth  of  the 
antrum  is  recorded  by  Mr.  Heath,  from  whose  work  we  take  the  fol- 
lowing description  by  Mr.  Bruce  : — 

"  It  appears  to  consist  of  a  fine,  soft,  fibrous  stroma,  in  which  very 
numerous  nuclear  bodies,  and  a  few  elongated  fibre-cells  are  dis- 
tributed.     Its   structure   resembles   that   of   the   upper   strata   of  a 


228  DENTAL  PATHOLOGY,  THEEAPEUTICS. 

mucous  membrane,  from  which  it  is  probably  an  outgrowth.  It  con- 
sists of  newly-formed  fibrous  tissue,  and  of  the  elements  from  which 
fibrous  tissue  is  developed,  and  may,  therefore,  be  classed  among  the 
simple  fibro-plastic  growths  as  distinguished  from  the  true  myeloid 
tumors." 

Fibrous  tumors  of  the  upper  jaw  are  not  unlike  fibrous  tumors 
found  elsewhere.  They  are  slow  of  growth,  dense  in  structure,  with 
interlacing,  slender  bundles  of  fibres,  and  are  frequently  lobulated. 
They  commonly  spring  from  the  interior  of  the  antrum,  or  from  the 
alveolus,  and  sometimes  attain  to  an  enormous  size,  crushing  in  the 
antrum  or  obliterating  its  walls  by  absorption,  encroaching  upon  the 
orbit,  destroying  its  floor,  penetrating  the  nasal  cavity,  and,  extending 
outward,  conceal  the  teeth  on  the  same  side  from  view.  Mr.  Liston 
removed  a  tumor  of  this  kind  from  the  face  of  a  lady,  where  it  had 
arisen  six  years  before,  apparently  from  a  blow  received  on  the  face, 
and  had  attained  to  an  enormous  size,  covering  the  whole  of  that  side 
of  the  face.  Its  smallest  diameter  was  six  inches.  This  tumor  became 
of  increased  vascularity  after  the  cessation  of  the  catemenia  at  the 
reo-ular  monthly  period,  and  bled  slightly  at  these  times,  from  the  ad- 
jacent parts  of  the  gum.  They  are  usually  of  an  oval  or  rounded 
form,  freely  movable,  and  painless.  When  laid  open  they  present  a 
white,  shining,  ligamentous  structure,  and  are  composed  of  nucleated 
fibres.  If  left  to  themselves  they  may  become  softened  in  the  centre 
and  undergo  disintegration,  though  Mr.  Heath  thinks  they  never 
suppurate,  except  where  they  have  been  punctured  in  establishing  a 
diao-nosis.  They  may  also  undergo  calcareous  degeneration,  but  are 
never  ossified. 

Mr.  Paget  reports  a  case  in  which  distinct  pulsation,  synchronous 
with  the  radial  pulse,  was  felt.  They  rarely  recur  after  removal, 
perhaps  never  when  entirely  removed.  Mr.  Weber  thinks  "they  are 
usually  connected  with  the  lining  of  the  Haversian  canals,"  and  ad- 
vises that  a  portion  of  the  bone  be  removed  in  all  operations.  Their 
origin  is  usually  referred  to  the  irritation  of  decayed  teeth,  or  to 
direct  violence. 

Fibro-cellular  tumor,  or  osteo-sarcoma,  is  of  softer  consistence  than 
the  simple  fibrous  tumor;  they  are  smooth,  round,  elastic  tumors,  of 
a  yellowish  color,  and  are  infiltrated  with  a  serous  fluid.  Unlike  the 
simple  fibrous  tumor,  they  exhibit  a  strong  tendency  to  ulceration, 
which  sometimes  serves  to  confound  them  with  malignant  growths, 
from  which  they  are  to  be  distinguished  by  the  history  of  the  case, 
and  the  non-implication  of  the  lymphatic  glands.  They  are  thus  de- 
scribed by  Sir  Philip  Crampton  :  "  In  the  earlier  stages  of  the  disease, 
the  tumor  consists  of  a  dense,  elastic  substance  resembling  fibro-car- 


TUMOES   OF   THE   MOUTH   AND   JAWS.  229 

tUaginous  structure,  but  the  resemblance  is  more  in  color  than  con- 
sistency, for  it  is  not  nearly  so  hard,  and  is  granular  rather  than 
fibrous,  so  that  it  '  breaks  short.'  On  cutting  into  the  tumor,  the  edge 
of  the  knife  grates  against  spicula,  or  small  grains  of  earthy  matter, 
with  which  its  substance  is  beset."  Fibro-cellular  tumors  may  undergo 
fatty  or  calcareous  degeneration. 

Recurring  fibroid  tumors  occur,  if  at  all,  so  rarely  in  the  upper  jaw, 
that  any  description  is  unnecessary  in  a  work  of  this  kind.  The  same 
may  be  said  of  vascular  tumors. 

Myeloid  tumors  are  described  by  Mr.  Paget  as  occupying  an  inter- 
mediate position  between  fibrous  and  fibro-cellular  tumors.  They  are 
composed  of  parallel  fibres,  with  fibro-plastic  cells,  and  bear  a  close 
resemblance  to  "  granulation  cells  in  process  of  development  into  fibro- 
cellular  tissue."  On  section  they  present  a  smooth,  shiny,  semi-trans- 
parent appearance ;  are  of  a  pinkish  or  bluish  color  and  of  brittle 
texture.  They  usually  occur  in  the  young ;  are  painless,  and  seldom 
recur.  Externally,  they  present  a  dark  maroon  color,  quite  character- 
istic. An  excellent  description  of  a  tumor  of  this  class  is  furnished 
Mr.  Heath  by  Dr.  Tonge,  from  which  we  make  the  following  extract : 
"  It  was  of  firm  consistence  throughout,  and  on  section  presented  a 
whitish  appearance,  with  a  small  pink  patch  or  two,  and  a  whitish? 
creamy-looking  juice  could  be  scraped  from  the  cut  surface. 
The  fibrous  element  was  much  less  abundant  than  the  cellular,  and 
consisted  of  white  fibrous  tissue,  with  numerous  fine  curling  fibres  of 
yellow  elastic  tissue,  and  many  small  oval  and  rounded  nuclei  were 
imbedded  in  the  fibrous  structure.  The  greater  portion  of  the  tumor 
seemed  to  be  composed  of  cells.  These  were  mostly  of  an  irregularly 
rounded  form,  often  with  pointed  processes,  and  some  shuttle-shaped 
and  spindle-shaped,  of  a  somewhat  trapezoidal  form,  were  not  uncom- 
mon, while  a  few  cells  presented  the  character  of  those  distinctive  of 
myeloid  tumors.  All  the  cells  contained  one,  and  often  two,  very  large, 
and  generally  oval  nuclei,  with  one,  two,  or  three  nucleoli,  and  a 
variable  number  of  oil  globules.  The  myeloid  cells  observed  were  of 
irregular  outline,  and  contained  from  three  to  five  nuclei,  with  single  or 
double  nucleoli ;  one  very  large  cell  contained  six  nuclei." 

Their  formation  takes  place  slowly,  after  the  manner  of  cyst  forma- 
tion, or  other  simple  tumors.  When  the  bone  has  been  removed  by 
absorption  or  otherwise,  they  may  be  recognized  by  their  characteristic 
color,  and  when  a  cyst  forms  within  them,  as  sometimes  happens,  mye- 
loid cells  may  be  found  in  the  fluid  that  escapes  when  it  has  been  punc- 
tured ;  thus  distinguishing  it  from  cystic  formations. 

Cartilaginous  tumors  are  of  two  kinds:  simple,  innocent  or  benig- 
nant tumors ;  and  tumors  presenting  a  malignant  appearance.     Those 


230  DEXTAL  PATHOLOGY,  THERAPEUTICS. 

of  the  first  class  present  a  round  or  ovoidal  form,  are  smooth,  hard,  of 
slow  growth,  and  painless.  Those  of  the  second  class  grow  with  gj-eat 
rapidity,  to  a  large  size,  and  are  of  a  malignant  appearance. 

Cartilaginous  tumors  occur  on  the  upper  jaw,  but  may  affect  it 
secondarily  by  extension  from  other  parts. 

Mr.  Heath  describes  several  specimens  taken  from  St.  George's  and 
St.  Bartholomew's  Hospitals  ;  in  one  of  which  the  disease  occurred  on 
the  inner  side  of  the  orbit,  and  two  years  later  had  ^^ressed  the  superior 
maxillge  forward  nearly  an  inch  beyond  the  inferior,  while  the  "  bones 
of  the  face  and  orbit  were  extensively  absorbed."  In  the  other,  the 
superior  maxillary  bones  were  entirely  absorbed,  the  cavity  of  skull 
was  invaded,  and  the  brain  pressed  aside ;  it  is  attached  to  the  soft 
palate  below,  and  presses  forward  the  walls  of  the  nose  in  front.  Mr. 
•Paget  relates  a  case  in  which  the  disease  had  existed  nine  years,  was 
removed,  but  returned,  and  the  patient  died  seven  years  after.  "  A 
section  of  the  tumor  showed  that  it  was  composed  of  an  outer,  hard, 
thin  shell  of  bone,  completely  inclosing  a  morbid  growth  of  spongy, 
cancellated  structure,  devoid  of  all  appearance  of  carcinomatous  or 
spongy  disease."  These  growths  are  usually  very  slow,  and  when  re- 
moved exhibit  but  a  slight  tendency  to  recur.  Cases  are  reported  in 
which  the  free  local  use  of  iodine  has  effected  the  absorption  of  tumors 
of  this  kind  that  had  not  yet  attained  a  large  size.  They  sometimes 
soften,  disintegrate,  slough,  and  establish  fistulous  openings,  through 
•which  a  jelly-like  mass  escapes. 

Osseous  tumors  in  their  simplest  form  are  but  a  hypertrophy  of 
previously  existing  bone  tissue.  They  are  predisposed  to  by  syphilitic 
and  scrofulous  affections,  and  sometimes  their  immediate  origin  may 
be  traced  to  the  irritation  of  imperfect  teeth ;  in  general,  however,  it 
is  difficult  to  refer  them  to  a  determinate  cause.  They  are  of  slow 
growth,  painless,  and  closely  resemble  true  bone  in  structure.  Their 
slowness  of  growth,  hardness,  painlessness  and  fixity,  are  the  charac- 
teristics on  which  a  diagnosis  may  be  based,  though  they  are  occasionally 
movable.  Occasionally  they  ulcerate,  and  troublesome  fistulous  open- 
ings are  established.  When  of  large  size  they  may  invade  important 
organs,  occasioning  great  trouble,  as  in  the  case  reported  by  Mr.  Hil- 
ton, where  it  invaded  the  orbit,  and  by  its  pressure  burst  the  ball  of 
the  eye. 

Cancerous  tumors  of  the  upper  jaw  are,  in  Mr.  Heath's  experience, 
limited  to  the  medullary  form  ;  other  observers  have,  however,  occa- 
sionally met  with  scirrhus.  Mr.  Hancock  advanced  the  view  that 
medullary  disease  does  not  begin  in  the  antrum,  but  in  the  bones  at 
the  base  of  the  skull.  This  view  is  refuted  by  the  observation  of  Mr. 
Listen  and  others,  who  have  shown  that  it  unquestionably  begins  in 


TUMORS   OF   THE   MOUTH   AND   JAWS.  231 

the  antrum  very  often.  They  are  characterized  by  rapid  develop- 
ment, softness  to  the  touch,  and,  when  fully  established,  by  a  peculiar 
expression  and  sallow,  putty-like  appearance  of  the  skin.  In  this 
situation  it  is  seldom  accompanied  by  glandular  enlargement.  By 
pressing  upon  the  nasal  duct  it  may  occasion  considerable  oedema  of 
the  lower  eyelid,  with  enlargement  of  the  facial  veins,  from  obstructed 
circulation. 

For  the  cure  of  all  solid  tumors  of  "the  upper  jaw,  there  is  but  one 
remedy  on  which  we  can  rely — the  knife.  All  operative  procedures 
should  be  resorted  to  at  the  earliest  practicable  moment,  before  the 
facial  structures  have  been  extensively  invaded  by  the  disease.  When 
the  disease  is  entirely  removed,  in  even  malignant  growths,  we  may 
sometimes  entertain  a  hope  of  permanent  relief.  To  effect  the  removal 
of  tumors  in  this  situation,  various  methods  have  been  devised.  Until 
1826,  surgeons  usually  contented  themselves  with  the  removal  of  so 
much  of  the  disease  as  could  be  effected  with  the  gouge  and  chisel ; 
but  about  this  time  Mr.  Lizars,  of  Edinburgh,  proposed  the  removal  of 
the  entire  superior  maxilla,  having  previously  secured  the  carotid 
artery.  An  opportunity  to  carry  out  his  suggestion  did  not  offer  until 
December  of  the  following  year,  when,  in  attempting  this  operation, 
the  hemorrhage,  notwithstanding  the  ligation  of  the  carotid,  was  so 
great  as  to  necessitate  the  discontinuance  of  the  operation.  In  the 
meantime,  without  any  knowledge  of  Mr.  Lizars'  suggestion,  Mr. 
Gensoul  successfully  removed  the  upper  jaw  without  securing  the 
artery,  and-  with  but  little  hemorrhage.  Mr.  Lizars  afterward  operated 
successfully,  and  the  operation  is  now  an  established  one.  His  incision 
was  carried  from  the  angle  of  the  mouth  to  the  malar  bone,  where  > 
when  more  space  was  required,  it  was  met  by  a  short,  vertical  incision, 
and  an  incision  was  also  made  from  the  middle  line  of  the  lip  to  the 
nostril.  Mr.  Gensoul  employed  a  vertical  incision  from  the  inner 
canthus  to  the  angle  of  the  mouth,  which  was  met  midway  by 
another  at  right  angles  to  it,  letting  fall  on  its  outer  extremity  another 
vertical  incision.  The  bone  was  then  removed  with  the  mallet  and 
chisel.  An  obvious  objection  to  these  operations  was  the  great  de- 
formity occasioned,  and  the  division  of  the  facial  nerve.  To  obviate 
these  difficulties.  Sir  William  Fergusson  suggested  a  plan,  which  has 
since  been  very  generally  adopted.  It  consisted  solely  in  an  incision 
from  the  middle  line  of  the  lip  to  the  nostril,  when,  by  stretching  the 
integument,  sufficient  space  was  usually  gained.  If  more,  however, 
was  required,  the  incision  was  carried  up  alongside  of  the  nose  to  the 
inner  canthus,  and  below  the  eye  to  the  outer  canthus,  thus  the  facial 
nerve  and  artery  were  divided  so  high  up  as  to  give  but  little  trouble, 
while  the  scars  are  most  favorably  situated  (See  Fig.  81). 


232 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


Fig.  81. 


After  deflecting  the  skin, 
a  small  saw  is  passed  into 
the  nostril,  with  which  the 
hard  palate  and  alveolus 
are  divided.  The  nasal  and 
malar  processes  of  the  su- 
perior maxilla  are  next 
sawed  nearly  through,  the 
division  completed  with 
bone  forceps.  The  bone  is 
then  grasped  by  the  power- 
ful forceps  devised  by  Sir 
William  Fergusson,  and 
forcibly  wrenched  from  its 
attachments  to  the  ptery- 
goid process  and  palate 
bones.  The  infra-orbital 
nerve  is  then  divided,  the 
soft  palate  carefully  dis- 
sected from  the  detached 
bone,  which  is  ready  for  removal.  After  which  hemorrhage  is  arrested 
by  ligatures  and  the  actual  cautery,  and  the  wound  closed  with  silver 
sutures.  When  the  palate  bone  and  orbital  palate  are  not  involved, 
they  may  be  spared  by  sawing  horizontally  above  and  below  them 
respectively.  Sir  William  Fergusson  now  prefers  to  avoid  the  removal 
of  all  healthy  tissue  by  attacking  the  disease  from  centre  to  circum- 
ference with  strong  curved  and  angular  bone  forceps.  Both  superior 
maxillae  have  occasionally  been  rem.oved ;  but  it  is  an  operation  so 
seldom  required  that  a  description  of  it  is  not  called  for  in  a  work  of 
this  kind. 

Tumors  of  the  lower  jaw  do  not  differ  in  essential  particulars  from 
those  already  described.  They  are  more  readily  diagnosed  and  safely 
removed  than  those  of  the  upper  jaw.  Deaths  are  comparatively  rare 
from  operative  procedures  here.  When  the  tumors  are  small,  they  may 
be  removed  without  incision  of  the  lip,  by  simply  dissecting  it  from  its 
attachment  to  the  bone,  tuj-ning  it  down,  and  removing  the  diseased 
portion  with  bone  forceps.  When  a  large  body  is  to  be  removed,  the 
incision  should  be  carried  beneath  the  margin  of  the  jaw,  where  the 
scar  shall  afterward  be  concealed  from  view.  When  the  bone  is  ex- 
posed, we  should  endeavor  carefully  to  ascertain  if  the  disease  may  not 
be  removed  with  the  external  plate  of  bone  alone  ;  if  this  may  not  be 
done,  the  saw  should  be  brought  into  requisition,  and  the  diseased 
structure  removed.     Amputation  of  the  lower  jaw  is  far  more  readily 


TUMORS   OF   THE   MOUTH   AND   JAWS.  233 

effected  than  of  the  upper;  for  a  detailed  account  of  this  operation  the 
student  is  referred  to  more  exclusively  surgical  works. 

"cystic  tumors,  dentigerous  cysts. 

It  must  be  remembered,  in  connection  with  diseases  of  the  antrum, 
that  it  is  of  variable  size,  with  walls  of  variable  thickness.  In  youth 
the  walls  are  thick  and  the  cavity  small.  After  attaining  its  maximum 
size  in  the  adult,  it  is  found  again  to  diminish  with  old  age  ;  it  is  larger 
in  males  than  in  females.  But  in  adult  life  its  capacity  varies  in  dif- 
ferent subjects,  from  one  drachm  to  eight  drachms,  the  average  capacity 
being  about  two  and  a  half  drachms. 

Suppurative  inflammation,  or  abscess  of  the  antrum,  is  commonly 
due  to  extension  of  inflammation  from  the  teeth  to  the  lining  mem- 
brane of  its  cavity.  The  roots  of  the  first  and  second  molars  not  infre- 
quently present  prominences  at  the  antrum,  and  sometimes  the  first 
molar  roots  are  found  extending  into  this  cavity  entirely  uncovered 
by  bone.  It  will,  therefore,  be  readily  seen  how  disease  of  the  roots 
may  prove  a  source  of  irritation  and  inflammation  to  the  lining  mem- 
brane of  this  cavity;  but  such  direct  communication  is  not  necessary  ; 
and  disease  beginning  in  alveoli  not  in  immediate  relation  with  the 
antrum  may  extend  through  intervening  bone  and  establish  commu- 
nication. Direct  blows  upon  the  face  may  also  induce  suppurative 
inflammation  of  its  membrane,  and  it  may  also  arise  from  "  pressure 
during  birth." 

The  symptoms  are,  pain  of  a  dull  character,  shooting  up  the  side  of 
the  face  and  head,  rigors  succeeded  by  irritative  fever,  with  tenderness 
and  swelling  of  the  cheek.  As  the  pus  accumulates,  the  pressure  to 
w^hich  it  subjects  the  walls  of  the  cavity,  together  with  the  vitiated 
nutrition  occasioned  by  its  presence,  determines  absorption  of  the  bone 
and  the  discharge  of  the  contained  fluid  through  the  opening  thus 
established  either  into  the  orbit  or  by  the  side  of  the  teeth.  Before  an 
opening  is  established,  however,  the  orbital  wall  may  become  so  dilated 
as  to  occasion  partial  blindness  by  displacement  of  the  eye,  or  it  may 
even  induce  an  amaurosis  which  shall  result  in  permanent  blindness. 
Sometimes  extensive  necrosis  is  occasioned,  afiecting  all  the  adjacent 
bones,  as  in  the  case  reported  by  Mr.  Salter,  in  which  the  "  floor  of 
the  orbit,  the  upper-cheek  portion  of  the  superior  maxilla,  and  the 
infra-orbital,  and  a  large  plate  of  bone  from  the  inner  (nasal)  wall  of 
the  antrum,  were  involved."  Dr.  Mair,  of  Madras,  reports  a  case  in 
which  death  resulted  in  sixteen  days,  though  apparently  beginning  as 
a  simple  ozsena.  The  post-mortem  examination  in  this  case  revealed 
a  condition  of  things  that  led  Dr.  Mair  to  conclude  that  it  began  as  a 
"  disease  of  the  antrum,  originating  in  degeneration  of  the  mucous 


234  DENTAL   PATHOLOGY,  THERAPEUTICS. 

membrane  lining  its  cavity,  or,  perhaps,  connected  with  the  soft  tumors 
which  grow  from  the  apex  of  the  tooth  and  from  the  lining  membrane 
of  the  root ;  secondarily,  involving  the  ethmoid,  lachrymal,  palatine, 
and  inferior  turbinated  bones  of  the  left  side,  causing  suppuration  and 
disintegration,  the  purulent  matter  filling  the  cavity  of  the  antrum  ex- 
tending toward  the  left  nostril,  causing  ozsena,  and  upward  into  the 
orbit,  behind  the  globe  of  the  eye,  pushing  the  eye  outward  and  for- 
ward, the  matter  finding  its  way  through  the  optic  foramen  to  the  ante- 
rior surface  of  the  left  hemisphere  of  the  brain,  there  acting  as  a 
foreign  body,  exciting  inflammatory  action,  terminating  in  cerebral 
abscess,  causing  convulsions,  coma,  and  death."  (Edinburgh  Medical 
Journal,  May,  1806.)  Cases  of  such  severity  are,  fortunately,  rare  ; 
but  they  indicate  the  possibilities  of  the  apparently  most  simple  cases, 
as  well  as  the  line  of  treatment  most  likely  to  obviate  such  conditions 
and  result. 

Treatment. — In  the  simplest  cases  in  which  suppuration  of  the  antrum 
is  strongly  suspected,  we  should  at  once  remove  all  decayed  teeth  or 
roots,  and  even  sound  teeth,  when  found  to  be  tender.  If  matter  has  not 
yet  formed,  the  disease  may  then  subside  under  the  use  of  simple  fomen- 
tations. It  is  safer,  however,  in  most  cases,  to  penetrate  the  antrum, 
prefei-ably  through  the  socket  of  the  first  molar,  because  of  the  greater 
depth  of  the  socket ;  and  this  too,  without  delay,  care  being  taken  to 
regulate  the  force  so  as  not,  by  too  great  violence,  to  injure  the  floor  of 
the  orbit.  Should  the  teeth  be  sound,  and  it  be  desired  to  save  them, 
an  opening  may  be  made  through  the  alveolus  above  the  gum.  The 
cavity  should  be  freely  injected  with  tepid  water,  and  subsequently  with 
some  slightly  stimulating  and  antiseptic  lotion;  and  care  must  afterward 
be  taken  to  prevent  the  admission  of  foreign  substances  into  the  cavity. 

In  the  more  chronic  forms  of  this  disease,  the  purulent  accumulation 
takes  place  so  slowly,  and  the  consequent  expansion  is  so  gradual,  that 
it  is  often  mistaken  for  solid  growths ;  and  in  many  cases  the  diagnosis 
is  of  extreme  difiiculty;  surgeons  of  distinction,  having  begun  an  ope- 
ration for  the  removal  of  a  solid  growth,  have  been  surprised  to  find 
their  hands  bathed  in  pus  whilst  the  supposed  tumor  disappeared  from 
beneath  them.  In  all  cases  in  which  the  diagnosis  is  not  perfectly 
clear,  an  exploratory  puncture  should  be  made,  and  thus  the  diflBculty 
is  at  once  resolved. 

Sometime  the  pus  is  inclosed  in  a  second  bony  investment,  due  to 
the  ossification  of  the  antral  periosteum.  When  this  occurs,  it  occa- 
sionally happens  that  the  bone  remains  thickened  long  after  the  evacu- 
ation of  the  pus  and  the  entire  cure  of  the  abscess,  the  deformity,  of 
course,  remaining  unaltered.  It  then  becomes  necessary  to  open  the 
antrum  and  remove  this  ossified  periosteum. 


TUMORS  OF  THE  MOUTH  AND  JAWS.  235 

A  clear  or  yellowish  serous  fluid  is  not  unfrequently  found  in  the 
antrum,  which  the  older  writers  took  to  be  a  secretion  of  mucus, 
which,  having  failed  to  make  its  escape  by  the  aperture  between  the 
antrum  and  the  nostril,  accumulated  in  such  quantity  as  to  occasion 
wasting  of  antral  walls  to  such  an  extent  as  to  permit  the  fluctuating 
mass  to  be  felt  at  certain  points.  This  fluid  was  found  on  examination 
to  contain  numerous  flakes  of  cholesterine,  as  is  the  case  in  well-defined 
cystic  growths,  and,  as  it  in  no  respect  resembled  mucus,  recent  writers 
have  referred  this  form  of  disease  to  cystic  formations. 

The  most  recent  and  able  writer  on  this  subject,  Mr.  Heath,  thus 
describes  their  mode  of  origin :  "  It  is  certain,  however,  that  some  of 
these  cases,  and  very  probably  all  of  them,  originate  in  the  growth  of 
a  cyst,  or  cysts,  within  the  antrum,  or  in  connection  with  the  fangs  of 
the  teeth,  which  either  grow  to  such  a  size  as  to  be  mistaken  for  the 
cavity  of  the  antrum  when  opened,  or  break  into  the  antrum  by  ab- 
sorption of  the  cyst- wall,  so  that  on  subsequent  examination  no  evidence 
of  the  cyst  formation  can  be  discovered." 

These  cyst  formations  are  also  occasionally  mistaken  for  solid 
growths ;  and  Mr.  Heath  relates  an  instance  in  which  "  a  very  able 
surgeon  removed  the  upper  jaw  before  the  mistake  was  discovered." 
And  Sir  William  Fergusson  relates  a  case  in  which  a  similar  error 
was  avoided  by  an  exploratory  puncture,  which  should  in  no  case  be 
omitted. 

They  may  be  single  or  multiple ;  sometimes  there  appears  to  be  a 
"  cystic  regeneration  of  the  entire  mucous  membrane."  Mr.  Giraldes, 
who  was  the  first  writer  on  this  subject,  thinks  they  are  due  to  "  dilation 
of  the  glandular  follicles  of  the  mucous  membrane,  and  that,  in  such 
cases,  it  will  be  necessary  to  open  the  antrum,  so  as  to  remove  the  entire 
mass ;  it  being  useless  in  such  cases  to  pursue  the  customary  plan  of 
tapping  the  antrum." 

Cysts  of  teeth  are  divided  by  Mr.  Heath  into  two  classes :  "  First, 
cysts  connected  with  the  roots  of  fully  developed  teeth ;  and,  secondly, 
cysts  connected  with  imperfectly  developed  teeth — to  which  the  term 
'  Dentigerous  Cysts '  has  been  applied  in  modern  times."  They  occur 
indifferently  in  either  jaw  ;  in  the  upper,  however,  are  sometimes  com- 
plicated with  collections  of  fluid  in  the  antrum,  which  they  have  sec- 
ondarily affected.  When  of  very  small  size  they  give  but  little  trouble, 
and  are  frequently  found  attached  to  the  roots  of  teeth  after  extraction, 
where  their  existence  had  not  before  been  suspected.  They  seem  to 
occur  most  frequently  in  connection  with  the  incisor  teeth,  and  some- 
times attain  a  very  large  size,  even  when  not  communicating  with  the 
antrum.  They  are  commonly  associated  with  the  disease  of  the  root 
about  which  they  are  formed,  whether  as  cause  or  effect,  it  is  difficult 


236  DENTAL  PATHOLOGY,  THERAPEUTICS. 

to  determine,  the  majority  of  observers  holding  the    latter  opinion. 
Fig.  82.  Mr.   Paget  relates  a  case  in 

which  the  cyst  contained  as 
much  as  an  ounce  of  fluid,  and 
was  received  in  a  deep  de- 
pression in  the  alveolar  bor- 
der of  the  jaw.  And  Delpech 
reports  one  containing  so  m  uch 
as  three  ounces,  without  con- 
nection with  the  antrum.  They 
cTSTs  coNKECTED  WITH  ROOTS  OF  TEETH.  coHslst  cssentially  of  a  scrous 

bag  growing  from  the  dental  periosteum  at  the  extremity  of  the  root, 
filled  with  a  clear  or  yellowish  fluid  with  bright  shining  particles  of 
cholesterine  floating  about  in  it.  According  to  Mr.  Tomes  the  morbid 
process  is  probably  identical  with  that  resulting  in  the  formation  of 
alveolar  abscess,  but  being  less  acute,  a  serous  cyst  is  formed  instead  of 
a  suppurating  one. 

Mr.  Heath  remarks  that  "  large  cysts  produce  more  or  less  absorption 
of  the  outer  wall  of  the  maxilla,  and  are  very  common  consequences  of 
diseased  teeth,  but  seem  to  give  surprisingly  little  inconvenience  to  the 
patients,  even  when  of  large  size  and  producing  considerable  deformity 
of  the  face.  They  are  commonly  confounded  with  cystic  distention  of 
the  antrum." 

Mr.  Heath  says  "  the  clinical  history  of  cysts  connected  with  the 
teeth  is  that  of  painless  expansion  of  the  alveolus,  more  frequently  of 
the  upper  jaw,  with  crackling  of  the  bone  on  pressure  and  ultimate 
absorption  of  the  bony  wall.  The  cyst  then  presents  a  bluish  appear- 
ance through  the  distended  mucous  membrane,  and  if  large,  gives  dis- 
tinct evidence  of  fluctuation."  "When  an  incision  is  made  into  the  cyst 
a  dark-colored  clear  fluid  escapes,  but  when  inflammation  is  present  the 
contents  become  purulent. 

The  treatment  of  such  cysts  consists  in  cutting  away  the  thin  outer 
wall,  so  that  the  cavity  may  granulate  up. 

Dentigerous  'cysts  occur  in  connection  with  teeth,  most  commonly 
permanent  teeth,  in  which  the  process  of  evolution  has  been  arrested, 
and  is  due,  Mr.  Tomes  thinks,  to  the  accumulation  of  fluid  between 
the  enamel  and  soft  outer  tissue  at  the  time  when  the  enamel  is  com- 
pleted, which  fluid  is  usually  discharged  when  the  tooth  is  erupted  ;  but 
when  the  tooth  remains  within  the  jaw,  this  discharge  cannot  take 
place,  and  it  continues  to  increase  in  quantity  until  a  cyst  is  established. 
We  are  thus  enabled  to  account  for  the  presence  of  cysts  in  those  cases 
in  which  neither  the  tooth  nor  adjacent  bone  presents  any  appearance 
of  disease.     In  illustration  of  this  theory,  Mr.  Tomes  relates  a  case  in 


TUMORS   OF   THE   MOUTH   AND   JAWS. 


237 


which,  "  instead  of  having  the  two  fangs  common  to  second  molars  of 
the  lower  jaw,  the  implanted  portion  of  the  tooth  was  dilated  into  one 
large  concavity,  in  which  was  placed  the  crown  of  a  second  tooth,  per- 
fectly invested  with  well  developed  enamel,  and  with  the  masticating 
surface  directed  toward  the  jaw.  The  two  teeth  appear  to  be  united 
by  dentine  at  one  point,  and  to  have  one  common  pulp  cavity.  .  .  . 
I  consider  that  in  the  case  cited,  fluid  collected  between  the  enamel  of 
the  inverted  tooth  and  the  remains  of  the  enamel  organ,  situated 
within  the  socket  of  the  second  molar.  As  the  cyst  enlarged,  the  con- 
tiguous bone  was  absorbed  to  make  room  for  it,  and  new  tissue  was 
concurrently  developed  on  the  outer  walls  of  the  socket  til),  at  last, 
a  large  cup  of  bone  was  formed."     ("  Dental  Surgery.") 


DENTiGERous  CYST  OF  LOWER  JAW.  6.  Showing  position  of  tooth. 

When  cysts  of  this  kind  occur  in  the  lower  jaw,  they  present  more 
obvious  deformity.  Sometimes  the  cyst  undergoes  calcification,  and  is 
exceedingly  difficult  to  diagnose  from  a  solid  tumor. 

Mr.  Heath  remarks  that  "  the  diagnosis  of  dentigerous  cysts  from 
other  cysts  is  exceedingly  difficult  until  they  are  opened,  as  indeed  is 
the  recognition  of  any  form  of  cyst.  A  careful  examination  of  the 
mouth  may  reveal  the  absence  of  a  permanent  tooth,  or  may  show  a 
temporary  tooth  occupying  a  permanent  position.  On  the  other  hand, 
however,  it  must  be  remembered  that  teeth  may  be  wanting  without 
being  connected  with  any  disease." 

Many  errors  of  diagnosis,  leading  to  operations  for  the  removal 
of  supposed  tumors,  have  been  made  by  able  and  distinguished  sur- 


238 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


geons,  who  have  had  the  courage  and  candor  to  confess  their  mistakes, 
among  whom  may  be  mentioned  Gensoul,  Syme,  Feavu,  and  Lisfranc. 
The  two  latter  gentlemen  each  removed  half  the  jaw.  It  is  only  when 
the  osseous  walls  have  become  so  wasted  as  to  give  under  pressure  a 
parchment-like  crackling  that  the  diagnosis  may  be  made  with  any 
approach  to  certainty.  In  every  case  an  exploratory  puncture  should 
be  insisted  on  before  proceeding  to  operate.  The  existence  of  a  cyst 
determined,  and  communication  with  the  antrum  suspected,  the  first 
molar  tooth  should  be  removed  and  the  wall  of  the  antrum  be  per- 
forated through  the  socket,  and  if  a  supernumerary  tooth  is  found  in 
the  cavity,  it  should,  of  course,  be  removed.  In  many  cases  it  is 
necessary  to  remove  the  front  wall  of  the  antrum  and  stuif  the  cavity 
with  lint,  thus  inducing  granulations,  before  a  cure  can  be  effected. 
This  can  generally  be  effected  without  incision  of  the  integument. 
AVhen  feasible,  the  plate  of  bone  removed  should  be  left  attached  to 
the  periosteum,  and  be  replaced  after  removal  of  the  cyst. 

Cysts  in  the  lower  jaw  present  some  peculiarities  which  make  a 
separate  description  necessary.     They  may  occur  in  connection  with 


Fig.  84. 


f\r~y^\ 


INVERTED   CROWNS   OF   TEETH  BETWEEN  EXPANDED  ROOTS  OF  OTHER  TEETH,  CAUSING  DENTIGEROUS  CYSTS. 

fully  developed  teeth,  or  without  any  direct  connection  with  the  teeth. 
They  may  be  multilocular,  and  in  rare  instances  may  contain  one 
within  another.  Mr.  Coote  reports  a  case  in  an  infant  of  six  months — 
which  resulted  in  death  from  exhaustion  occasioned  by  continued  dis- 
charge after  an  operation — in  which,  covered  by  a  thin  shell  of  bone, 
a  perfect  nest  of  cysts  connected  with  the  antrum  have  been  shown 
to  arise  in  the  glandular  structure  of  its  lining  membrane,  but  in 
the  lower  jaw  we  have  no  such  membrane.  Instead  thereof,  we 
have  two  layers  of  laminated  bone  enclosing  a  cancellated  structure 
lined  by  the  endosteum  alone.  Mr.  Heath  is  of  opinion  that  it  is  in 
these  cancelli  the  disease  is  developed,  "  A  cancellus  expanding  and 
producing  gradual  absorption  and  oblitei'ation  of  its  neighbors  until 
a  cyst  of  considerable  size  is  produced."  The  causation  of  cystic 
formations  in  the  lower  jaw  is  very  obscure,  though  they  are  probably 
associated  in  some  way  with  the  irritation  from  adjacent  roots.  They 
may  continue  to  reproduce  themselves,  from  time  to  time,  until  the 
cancellated  tissue  is  entirely  destroyed. 


TUMORS  OF  THE  MOUTH  AND  JAWS. 


239 


Cysts  in  connection  with  undeveloped  teeth — dentigerous  cysts — 
■which  ai-e  common  to  both  jaws,  may  suppurate  and  form  abscesses. 
They  generally  occur,  in  the  case  of  unerupted  teeth,  from  some  irri- 
tation, and  are  more  common  to  permanent  than  to  deciduous  teeth. 
Inversion  of  the  tooth  also  appears  to  be  a  cause  of  these  cysts. 

Mr.  Heath  remarks  that  "  when  dentigerous  cysts  occur  in  the  lower 
jaw  they  form  more  isolated  and  prominent  tumors  than  in  the  case  of 
the  upper  jaw,  and  in  some  cases  the  projecting  bony  wall  has  been 
removed." 

The  treatment  of  dentigerous  cysts  consists  in  a  free  incision  and 
the  removal  of  the  unerupted  tooth,  as  a  simple  puncture  will  not 
answer.    The  front  wall  of  the  cyst  should  be  removed,  and  the  cavity 


Fig.  85. 


Fig.  86. 


DENTIGEROUS   CTST   DUE   TO   NON-DEVELOPMENT   OF   OANIJJE   TOOTH. 

filled  with  lint,  "  so  as  to  induce  granulation  and  gradual  obliteration." 
This  may  be  accomplished  in  the  majority  of  cases  without  any  incision 
of  the  integuments.  After  the  removal  of  a  portion  of  the  cyst  wall,  in 
the  case  of  dentigerous  cysts  of  the  lower  jaw,  the  plates  should  be  pressed 
together  as  much  as  possible;  and  the  same  may  be  accomplished 
in  the  case  of  the  upper  jaw  by  the  pressure  of  pads  and  bandages. 
Mr.  Heath  directs  that  the  cyst  should  always  be  reached  by  dividing 
the  mucous  membrane  within  the  mouth,  and  without  incising  the 
cheek  ;  but  if  necessary,  a  single  line  of  incision  only  should  be  made, 
so  that  as  little  after-deformity  as  possible  may  be  produced. 

Unilocular  cysts  are  to  be  treated  simply  by  extracting  adjacent 
teeth,  and,  after  evacuating  the  contents,  when  the  walls  are  thin. 


240  DENTAL   PATHOLOGY,  THERAPEUTICS. 

crushing  them  in  so  as  to  diminish  the  size  of  the  cavity.  According 
to  Mr.  Eve  multilocular  cysts,  so  far  from  having  a  dental  origin,  are 
produced  by  an  ingrowth  of  the  epithelium  of  the  gum.  They  may 
result  from  injury,  the  irritation  of  decayed  teeth,  or  long  continued 
inflammation.  They  are  of  slow  growth,  and  present  very  little  ten- 
dency to  implicate  surrounding  parts.  Multilocular  cysts  are  found 
in  the  lower  jaw,  consisting  of  cells  varying  in  size  from  that  of  a  pea 
to  others  occupying  the  entire  thickness  of  the  bone. 

Multilocular  cysts  may  be  treated  according  to  the  plan  of  Mr. 
Butcher,  which  consists  in  dividing  the  raucous  membrane  over  the 
cyst  freely,  and  then  with  a  gouge  and  bone-forceps  removing  the 
expanded  external  plate  of  the  bone,  with  the  contents  and  lining 
membrane  of  the  cyst,  interfering  with  the  teeth  as  little  as  possible, 
and  avoiding  the  facial  artery.  Dr.  Mason  Warren  recommends  a 
more  conservative  practice  than  that  of  Mr.  Butcher.  His  treatment 
consists  in  the  puncture  of  the  sac  within  the  mouth,  and  at  the  same 
time  obliterating  its  cavity  by  crushing ;  then  to  keep  up,  by  injec- 
tions, etc.,  a  sufficient  degree  of  irritation  to  favor  the  deposition  of 
new  bone. 


CHAPTER  VI. 

SALIVARY    CALCULUS. 


THE  color,  consistence,  and  quantity  of  salivary  calculus,  or  tartar, 
as  it  is  most  commonly  called,  vary  in  different  temperaments, 
and  upon  all  of  them  the  state  of  the  general  health  exercises  consid- 
erable influence.  The  characteristics  of  this  substance,  therefore,  fur- 
nish diagnoses,  important  both  to  the  physician  and  dentist.  Their 
indications  are,  in  many  cases,  less  equivocal  than  the  appearances  of 
any  other  part  of  the  mouth ;  but,  like  those  of  the  gums,  should  not, 
perhaps,  be  alone  relied  upon.  It  is  necessary  to  interrogate  every 
part  from  which  information  can  be  derived  concerning  the  patho- 
logical condition  of  the  several  organs  of  the  body. 

Salivary  calculus  is  composed  of  earthy  salts  and  animal  matter. 
Phosphate  of  lime  and  fibrine,  or  cartilage,  are  its  principal  ingredi- 
ents ;  a  small  quantity  of  animal  fat,  however,  enters  into  its  compo- 
sition, and  the  relative  proportions  of  its  constituents  vary  accordingly 
as  it  is  hard  or  soft,  or  as  the  temperament  of  the  individual  from  whose 
mouth  it  is  taken  is  favorable  or  unfavorable  to  health.  Hence  it  is 
that  the  analyses  that  have  been  made  of  it  by  different  chemists  differ. 
No  two  give  the  same  result. 


SALIVARY   CALCULUS.  241 

The  black,  dry  tartar  deposited  around  the  necks  of  the  teeth  of 
such  only  as  have  good  constitutions,  is  never  in  large  quantities  ;  it  is 
dissolved  in  muriatic  acid  with  difficulty,  while  the  dry,  light-brown 
tartar  found  upon  the  teeth  of  bilious  persons  dissolves  more  readily 
in  it;  but  the  soft,  white  tartar,  found  upon  the  teeth  of  individuals  of 
neuro-lymphatic  temperaments,  is  scarcely  at  all  soluble  in  the  acids, 
but  is  readily  dissolved  in  the  alkalies. 

All  persons  are  subject  to  salivary  calculus,  but  not  alike ;  it  collects 
on  the  teeth  of  some  in  larger  quantities  than  on  those  of  others,  and  its 
chemical  and  physical  characteristics  are  exceedingly  variable.  It  is 
sometimes  almost  wholly  composed  of  calcareous  ingredients;  at  other 
times  these  constitute  but  about  one-half,  or  little  more  than  one-half, 
of  its  substance,  the  remainder  being  made  up  of  animal  matter.  Nor 
is  its  color  more  uniform.  Sometimes  it  is  black,  at  other  times  it  is 
of  a  dark,  pale,  or  yellowish  brown,  and  in  some  instances  it  is  nearly 
white.  It  also  differs  in  density.  In  the  mouths  of  some  it  has  a 
solidity  of  texture  nearly  equal  to  that  of  the  teeth  themselves;  in 
others,  it  is  so  soft  that  it  can  be  scraped  from  the  teeth  with  the  thumb- 
or  finger-nail.  The  black  kind  is  the  hardest,  the  white  the  softest, 
and  its  density  is  increased  or  diminished  as  it  approaches  the  one  or 
the  other  of  these  colors. 

Salivary  calculus  collects  in  very  small  quantities  on  the  teeth  of 
persons  possessed  of  the  most  perfect  constitutions,  and  even  on  these  it 
is  seldom  found  except  on  the  inner  surfaces  of  the  lower  incisors  next 
the  gums.  It  is  then  black,  or  of  a  dark  brown,  very  dry,  and  almost 
as  hard  as  the  teeth,  to  which  it  adheres  with  great  tenacity. 

It  rarely  happens  that  any  unpleasant  effects  are  produced  by  the 
presence  of  this  kind  of  tartar  upon  the  teeth.  The  general  health 
is  never  affected  by  it,  and  the  only  local  injury  that  results  from  it  is 
slight  turgidity  of  the  edge  of  the  gums  in  immediate  contact  with  it. 

The  indications,  therefore,  of  this  description  of  tartar  are  favorable, 
both  with  regard  to  the  teeth,  gums,  and  organism  generally.  The 
teeth  upon  which  it  is  found  are  of  an  excellent  quality,  and  rarely 
affected  by  caries.  They  have  the  characteristics  represented  as  be- 
longing to  the  best  kind,  and  teeth  of  this  description  are  only  found 
among  persons  having  good  innate  constitutions. 

There  is  another  kind  of  black  tartar,  differing  from  this  in  many 
particulars.  It  is  found  in  the  mouths  of  those  having  good  constitu- 
tions, but  whose  physical  powers  have  been  enervated  by  privation  or 
disease,  or  intemperance  and  debauchery,  and  most  frequently  by  the 
last  named.  It  is  found  in  large  quantities  on  the  teeth  opposite  the 
mouths  of  the  salivary  ducts ;  it  is  exceedingly  hard,  and  agglutinated 
so  firmly  to  the  organs  that  it  is  removed  with  great  difficulty;  it  is 
i6 


242  DENTAL  PATHOLOGY,  THERAPEUTICS. 

very  black,  has  a  rough  and  uneven  surface,  and  is  covered  with  a 
glairy,  viscid,  and  almost  insufferably  offensive  mucus. 

The  presence  of  this  kind  of  salivary  calculus  is  attended  with  very 
hurtful  consequences,  not  only  to  the  gums,  alveolar  processes,  and 
teeth,  but  also  to  the  general  health.  It  causes  the  gums  to  inflame, 
swell,  suppurate,  and  recede  from  the  teeth,  the  alveoli  to  waste,  and 
the  teeth  to  loosen  and  frequently  to  drop  out.  The  secretions  of  the 
mouth  are  also  vitiated  by  it,  and  rendered  unfit  to  be  taken  into  the 
stomach.  Hence,  as  long  as  it  is  permitted  to  remain  on  the  teeth, 
neither  the  skill  of  the  physician  nor  the  best  regulated  regimen, 
though  they  may  afford  partial  and  temporary  relief,  will  fully  restore 
to  the  system  its  healthy  functions. 

As  this  kind  of  tartar  is  seldom  if  ever  met  with  except  in  constitu- 
tions naturally  excellent,  the  teeth  on  which  it  is  deposited  are  generally 
sound,  but  they  are  often  caused,  by  the  disease  which  is  produced  in 
the  gums  and  alveoli,  to  loosen  and  drop  out. 

The  dark-brown  tartar  is  not  so  hard  as  either  of  the  descriptions 
of  black.  It  sometimes  collects  in  tolerably  large  quantities  on  the 
lower  front  teeth  and  on  the  first  and  second  superior  molars ;  it  is  also 
often  found  on  all  the  teeth,  though  not  in  as  great  abundance  as  on 
these.  It  does  not  adhere  with  as  much  tenacity  as  either  of  the  pre- 
ceding kinds,  and  can  be  more  easily  detached  fi'om  them.  It  exhales 
a  moi'e  fetid  odor  than  the  first  variety,  but  is  less  offensive  than  the 
second. 

The  persons  most  subject  to  this  kind  of  tartar  are  of  mixed  tem- 
peraments, the  sanguineous,  however,  always  predominating.  They 
may  be  denominated  sanguineo-serous  and  bilious.  Their  physical 
organization,  though  not  the  strongest  and  most  perfect,  may,  never- 
theless, be  considered  very  good.  But,  being  more  suscejjtible  to 
morbid  impressions,  their  general  health  is  less  uniform  and  more 
liable  to  impairment  than  those  possessed  of  the  most  perfect  con- 
stitutions. 

The  effects  arising  from  the  accumulations  of  this  description  of 
salivary  calculus,  both  local  and  constitutional,  are  less  hurtful  than 
the  variety  last  noticed  ;  but,  like  that,  it  causes  the  gums  to  inflame, 
swell,  suppurate,  and  to  retire  from  and  expose  the  necks  of  the  teeth, 
the  alveoli  to  waste,  the  teeth  to  loosen  and  sometimes  to  drop  out. 
It  also  gives  rise  to  a  vitiated  condition  of  the  fluids  of  the  mouth. 

Salivary  calculus  of  a  light  or  pale  yellowish- brown  color  is  of  a 
much  softer  consistence  than  the  darker  varieties,  and  is  seldom  found 
upon  the  teeth,  except  of  persons  of  bilious  temperament,  or  those  in 
whom  this  predominates.  It  has  a  rough  and,  for  the  most  part,  a  dry 
surface ;  it  is  found  in  large  quantities  opposite  the  mouths  of  the  sali- 


SALIVARY   CALCULUS.  243 

vary  ducts,  and  sometimes  every  tooth  in  the  mouth  is  completely 
imbedded  in  it.  It  contains  less  of  the  earthy  salts  and  more  of  the 
animal  matter  than  any  of  the  foregoing  descriptions,  and  from  the 
quantity  of  vitiated  mucus  in  and  adhering  to  it,  has  an  exceedingly 
offensive  smell.  It  is  sometimes,  though  not  always,  so  soft  that  it 
may  be  crumbled  between  the  thumb  and  finger. 

Inflammation,  turgescence,  and  suppuration  of  the  gums,  inflamma- 
tion of  the  alveolo-dental  periosteum,  the  destruction  of  the  sockets  and 
loss  of  the  teeth,  and  an  altered  condition  of  the  fluids  of  the  mouth, 
are  among  the  local  effects  produced  by  the  long  continued  presence 
of  large  collections  of  this  variety  of  tartar.  The  constitutional  effects 
are  not  much  less  pernicious.  Indigestion  and  general  derangement 
of  all  the  assimilative  functions  are  among  the  most  common.  When 
the  deposit  is  not  large,  inflammation  and  sponginess  of  such  parts  of 
the  gums  as  are  in  immediate  contact  with  it,  and  fetid  breath,  are  the 
principal  of  the  unpleasant  effects  produced  by  it. 

White  tartar  rarely  collects  in  very  large  quantities,  and  though 
most  abundant  on  the  outer  surfaces  of  the  first  and  second  superior 
molars  and  the  inner  surfaces  of  the  lower  incisors,  it  is  nevertheless 
frequently  found  on  all  the  teeth.  Its  calcareous  ingredients  are  less 
abundant  than  those  of  any  of  the  preceding  descriptions.  Fibrine, 
animal  fat  and  mucus  constitute  by  far  the  larger  portion  of  its  sub- 
stance. It  is  very  soft,  seldom  exceeding  in  consistence  common 
cheese-curd,  to  which  in  appearance  it  bears  considerable  resemblance. 
Although  it  exerts  but  little  mechanical  irritation  upon  the  gums,  it 
keeps  up  a  constant  morbid  action  in  them.  Its  effects,  however,  upon 
the  teeth  are  far  more  deleterious  than  any  other  description  of  tartar. 
It  corrodes  the  enamel,  and  causes  rapid  decay  of  the  organs.  The 
fluids  of  the  mouth  are  also  vitiated  by  it. 

It  is  only  upon  the  teeth  of  persons  of  mucous  habit,  or  those  who 
have  suffei'ed  from  diseases  of  the  mucous  membranes,  or  those  in 
whom  these  tissues  have  been  more  or  less  involved,  that  this  kind  of 
tartar  accumulates. 

There  is  one  other  kind  of  deposit  described  by  dental  writers.  It 
is  of  a  dark-green  color,  and  is  seen  more  frequently  on  the  anterior 
surfaces  of  the  upper  teeth  occupying  the  front  part  of  the  mouth, 
than  on  any  of  the  others.  It  resembles  more  closely  a  stain  on  the 
enamel  than  salivary  calculus.  Children  and  young  persons  are  more 
subject  to  it  than  adults,  though  it  is  occasionally  observed  on  the 
teeth  of  the  latter.  It  has  the  effect  of  corroding  the  enamel  of  soft 
teeth;  the  margins  of  the  gums  around  such  teeth  having  it  on  them 
are  inflamed,  and  the  sanguineous  capillaries  of  their  whole  substance 
appear  to  be  distended  and  more  than  ordinarily  languid. 


244  DENTAL  PATHOLOGY,  THERAPEUTICS. 

This  kind  of  discoloration  of  the  enamel  is  indicative  of  an  irritable 
condition  of  the  mucous  membranes  and  viscidity  of  the  fluids  of  the 
mouth.  Sour  eructations,  vomitings,  diarrhoea  and  dysentery  are  not 
unfrequent  with  those  whose  teeth  are  thus  affected.  While  the  pres- 
ence of  this  green  stain  on  lately  erupted  teeth  is  almost  a  certain  indi- 
cation of  softened  enamel,  this  is  not  the  case  when  it  is  deposited  on 
adult  and  very  dense  teeth.  It  does  not  appear  to  be  a  precipitate 
from  the  mucus,  as  salivary  calculus  is  from  the  saliva,  but  is  rather 
a  growth  of  fungi  upon  the  surface,  and  it  is  yet  an  open  question 
whether  it  developes  its  own  acid,  as  in  the  case  of  the  "sprosspilz" 
lately  described  by  Dr.  Miller,  or  whether  it  retains  the  neutral  secre- 
tions to  the  acidulated  stage. 

According  to  Wedl,  it  may  "  readily  be  demonstrated  that  the  de- 
posit is  a  green,  greenish-yellow,  uniformly  minutely  granular  mass 
which  is  morphologically  identical  with  the  matrix  of  leptothrix." 

Tartar  or  salivary  calculus  sometimes  accumulates  in  very  large 
quantities,  giving  to  the  mouth  a  most  disagreeable  and  repulsive 

Fig.  87.  Fig.  88. 


aspect,  and  imparting  to  the  breath,  not  unfrequently,  an  almost  in- 
sufferably offensive  odor.  Fig.  87  represents  a  set  of  teeth  incrusted 
with  it,  and  Fig.  88  a  single  tooth,  presented  to  the  author  by  Dr.  W. 
Allen,  of  Massachusetts,  with  the  largest  accumulation  of  this  substance 
he  has  ever  seen  in  one  mass.  Its  longest  diameter  is  an  inch  and  an 
eighth,  its  shortest  seven-eighths,  and  its  thickest  five-eighths  of  an  inch. 
Imbedded  in  its  substance  is  the  entire  crown  and  neck  of  a  lower  dens 
sapientire,  which  was  removed  with  it.  It  is  of  a  light-brown  color, 
and  weighs  two  drachms  and  seventeen  grains. 

The  late  Prof.  Austen  described  a  remarkable  case  where  every  tooth, 
above  and  below,  had  been  loosened  by  alveolar  absorption  caused  by 
this  deposit ;  no  tooth  having  more  than  an  eighth  of  an  inch  depth 
of  socket,  and  some  of  them  held  only  by  an  exceedingly  tough  at- 
tachment to  the  gum  and  periosteum.  The  tartar  upon  the  lower  in- 
cisors was  equal  to  five  times  the  size  of  the  teeth,  most  of  it  being 
on  the  inside,  and  three-quarters  of  an  inch  thick  at  the  base.  A 
singular  peculiarity'in  this  case  was  the  excessive  pain  of  extraction. 


SALIVARY   CALCULUS.  245 

Small  as  was  the  attachment,  it  was  uncommonly  firm  ;  and  the  patient, 
a  working-man,  was  laid  up  with  nervous  prostration  for  two  weeks 
after  the  operation. 

CHEMICAL    CONSTITUENTS    OF   SALIVARY    CALCULUS. 

Salivary  calculus  is  composed  of  phosphate  of  lime  and  animal  matter  ; 
combined  in  various  proportions,  accordingly  as  it  is  hard  or  soft ;  con- 
sequently no  two  analyses  will  yield  the  same  result. 

Berzelius  gives  the  following  analysis.  He  found  one  hundred  parts 
to  contain — 

Phosphate  of  lime  and  magnesia, 79.0 

Salivary  mucus  and  salivine,        .         .         .         .         .         .13.5 

Animal  matter,    .         .         .         .         .         .         .         .         .         7.5 


Dr.  W.  H.  Dwinelle  furnishes  the  following: — 


100.0 


Phosphate  of  lime,        ........  60 

Carbonate  of  lime,       ........  14 

Animal  matter  and  mucus,            ......  16 

Water  and  loss,    .........  10 

100 

The  last  named  gentleman  acknowledges  that  he  could  make  no  two 
analyses  agree.  Hard,  dry  tartar  contains  more  earthy  and  less  animal 
matter  than  the  soft,  humid  tartar. 

Chemical  analysis  reveals  a  large  proportion  of  mucus,  as  is  shown 
by  the  following  table  of  Vaqueliu  and  Langier  : — 

Phosphate  of  lime  and  a  little  magnesia,       ....  66 

Carbonate  of  lime, 9 

Salivary  mucus  (including  ptyalin), 13 

Animal  matter  soluble  in  hydrochloric  acid,          ...  5 

Water  and  loss, 7 


100 

An  analysis  of  saliva  reveals  water,  ptyalin,  fat,  chloride  of  sodium 
chloride  of  potassium,  phosphate  of  lime,  and  sulphocyanide  of  po- 
tassium. 

The  infusoria  of  which  M.  Mandl  says  tartar  is  composed,  have  their 
origin  in  the  vitiated  mucus  which  is  always  mixed  with  it. 

Scherer  detected  with  a  microscope  infusoria,  in  large  numbers,  in 
the  saliva  of  a  girl  laboring  under  a  scorbutic  affection  of  the  mouth  ; 
but  the  author  is  inclined  to  believe  that  they  had  their  origin  in  the 
mucous  secretions  of  this  cavity,  which  are  always  mixed  with  the 


246  DENTAL  PATHOLOGY,  THERAPEUTICS. 

former  fluid.  They  are  more  or  less  numerous,  as  the  tartar  is  hard 
or  soft,  or  in  proportion  to  the  quantity  of  mucus  that  enters  into  its 
composition.* 

ORIGIN   AND    DEPOSITION    OF    SALIVARY   CALCULUS. 

There  formerly  existed  much  diversity  of  opinion  as  to  the  source 
whence  salivary  calculus  is  derived  ;  but  it  is  now  generally  conceded 
that  this  deleterious  concretion  is  a  deposit  chiefly  from  the  saliva,  with 
an  admixture  of  mucus,  as  the  analyses  of  both  these  secretions  reveal 
the  necessary  materials  in  sufficient  quantity  to  form  it.  Bidder  and 
Schmidt  make  the  phosphates  and  carbonates  amount  to  very  nearly 
one  per  cent,  in  the  saliva.  All  that  is  necessary,  therefore,  is  that  the 
surfaces  of  the  teeth  should  have  a  sufficient  affinity  for  the  substance 
in  question  to  cause  a  nucleus,  which,  when  once  formed,  the  secretion 
continues  until  serious  secondary  effects  are  liable  to  result. 

In  most  varieties  of  salivary  calculus  there  is  a  notable  superabun- 
dance of  the  phosphates  and  carbonates,  while  in  others  there  is  nearly 
forty  per  cent,  of  purely  animal  matter.  Hence  the  difference  in  action 
upon  thera  by  acids  and  alkalies.  Of  the  animal  matter  entering  into 
the  composition  of  salivary  calculus,  fibrin,  animal  fat  and  mucus  are 
in  the  largest  proportion. 

Of  the  existence  of  the  elements  of  the  composition  of  calculus  in 
the  saliva  there  can  be  no  question.  Chemical  analyses  of  this  fluid, 
direct  from  the  glands,  place  all  doubt  upon  the  subject  at  rest.  Thus 
it  is  seen  that  the  chief  earthy  constituents  which  enter  into  the  forma- 
tion of  this  substance  are  contained  in  the  saliva.  It  may  also  exist  in 
solution  in  the  mucous  fluid  of  the  mouth. 

That  the  deposition  of  tartar  may  take  place  on  one  side  of  the 
mouth  without  a  similar  deposit  on  the  opposite  side,  furnishes  no  evi- 
dence in  support  of  the  doctrine  which  has  been  advanced,  that  it  is 
an  exhalation  from  the  capillaries  of  the  mucous  membrane  of  the 
gums.  The  mastication  of  food  is,  with  most  persons,  performed  more 
on  one  side  of  the  mouth  than  on  the  other ;  that  this  function  pre- 
vents, in  a  great  degree,  the  accumulation  of  tartar  on  the  organs 
immediately  concerned,  is  a  fact  with  which  every  dentist  must  be 
familiar.  Hence  its  frequent  collection  on  the  teeth  of  one  side  and 
not  on  those  of  the  other.  And  that  it  is  ascribable  to  this  circum- 
stance is  susceptible  of  positive  proof.  If,  on  the  removal  of  the  tar- 
tar from  the  teeth  of  a  person  in  whose  mouth  it  has  collected  only 
on  those  of  one  side,  mastication  be  afterward  altogether  performed  on 
this  side,  it  will  not  reaccumulate  on  them  ;  and  if  requisite  attention 

*  Dr.  Dwinelle  gives  a  minute  description  of  their  appearance  in  the  first  num- 
ber of  the  fifth  volume  of  the  American  Journal  of  Dental  Science. 


SALIVARY   CALCULUS.  247 

to  the  cleanliness  of  the  teeth  on  the  other  side  be  not  observed,  it 
will  soon  collect  there,  although  these  teeth  had  before  remained  free 
from  it. 

Again,  it  often  happens  that  disease  of  a  severe  character  is  excited 
in  the  gums  by  the  use  of  mercurial  medicines  and  other  causes,  and 
yet  but  a  small  quantity  of  tartar  collects  on  the  teeth ;  but  that  any 
condition  of  the  general  system,  or  of  the  mouth,  tending  to  make  the 
fluids  of  this  cavity  more  viscid,  promotes  its  formation,  is  undeniable. 
There  are,  however,  some  temperaments  much  more  favorable  to  its 
production  than  others;  and  it  is  a  well-established  fact,  that  the 
mucous  membrane  of  those  in  whose  mouths  it  accumulates  in  largest 
quantity  is  the  most  irritable,  and  the  buccal  fluids  most  viscid.  Again, 
if  it  were  deposited  by  the  mucous  fluids  of  the  mouth,  it  would  col- 
lect in  largest  quantities  on  those  teeth  which  are  less  abundantly 
bathed  in  the  saliva ;  as,  for  example,  the  anterior  surfaces  of  the 
upper  incisors  and  cuspids,  while  those  opposite  to  the  mouths  of  the 
ducts  which  discharge  this  fluid  into  the  mouth  would  be  less  liable  to 
deposits  of  tartar  than  any  of  the  other  teeth  ;  whereas  the  contrary  is 
found  to  be  the  case. 

The  conclusion,  therefore,  appears  to  us  irresistible,  that  this  earthy 
matter  is  chiefly  a  salivary  deposit,  and  takes  place  in  the  following 
manner :  It  is  precipitated  from  the  saliva,  as  this  fluid  enters  the 
mouth — especially  when  the  secretion  is  sluggish — upon  the  surfaces  of 
the  teeth  oj)posite  the  openings  into  the  ducts  from  which  it  is  poured. 
To  these  its  particles  become  agglutinated  by  the  mucus  always  found, 
in  greater  or  less  quantity,  upon  them.  Particle  after  particle  is  de- 
posited, until  it  sometimes  accumulates  in  such  quantities  that  nearly 
all  the  teeth  are  almost  entirely  incrusted  with  it. 

As  regards  the  points  of  deposit  of  salivary  calculus,  the  greatest 
quantities  are  found  opposite  the  mouths  of  the  ducts  of  the  salivary 
glands,  upon  the  lingual  surfaces  of  the  inferior  incisors,  cuspidati  and 
bicuspids,  and  the  buccal  surfaces  of  the  superior  molars.  The  necks 
of  the  teeth,  about  the  free  margins  of  the  gums,  afi'ord  favorable 
points  for  its  collection,  as  here  the  saliva  is  longer  retained  and  its 
calcareous  ingredients  precipitated,  than  upon  more  exposed  parts.  It 
first  collects  about  the  necks  of  the  teeth  in  semi-circular  or  crescent- 
like  lines  close  to  the  enamel,  under  the  edge  of  the  gums,  and  a 
nucleus  being  once  formed,  it  rapidly  encroaches  upon  the  crown,  where 
it  is  deposited  more  abundantly.  Certain  varieties  of  salivary  calculus 
adhere  to  the  necks  of  the  teeth  with  great  tenacity,  and  often  progress 
as  far  as  the  apex  of  the  root,  until  the  teeth  are  deprived  of  their 
support,  and  their  roots  left  denuded  and  exposed.  Salivary  calculus 
is  never  deposited  on  the  flesh,  but  only  upon  such  substances  as  rep- 


248  DENTAL,  PATHOLOGY,  THERAPEUTICS. 

resent  the  teeth  or  form  nuclei,  as  artificial  teeth,  for  example.  It  is 
sometimes  deposited  in  the  ducts,  which  may  be  owing  to  a  sluggish 
condition  of  the  saliva,  in  a  form  known  as  ranula,  and  has  been 
removed  in  a  mass  as  large  as  a  hazel-nut. 

M.  Robert  presented  to  the  Anatomical  Society  of  Paris  a  hog's 
bristle,  which  had  been  forced  into  the  duct  of  Wharton,  densely 
covered  with  a  thick  salivary  concretion. 

From  the  fact  that  salivary  calculus  is  often  found  upon  parts  where 
the  saliva  cannot  be  retained  for  any  length  of  time,  it  is  evident  that 
it  is  sometimes  precipitated  as  soon  as  this  fluid  enters  the  mouth. 

EFFECTS  OF  SALIVARY  CALCULUS  UPON  THE  TEETH,  GUMS,  AND 
ALVEOLAR  PROCESSES. 

.  Although  salivary  calculus  does  not  directly  act  injuriously  upon  the 
substance  of  the  teeth,  but,  on  the  contrary,  preserves  the  part  it 
covers  from  the  action  of  chemical  agents,  yet  the  effects  of  the  presence 
of  this  substance  are  always  pernicious,  though  sometimes  more  so 
than  at  others.  An  altered  condition  of  the  fluids  of  the  mouth,  dis- 
eased gums,  and  not  unfrequently  the  gradual  destruction  of  the  alve- 
olar processes,  and  the  loosening  and  loss  of  the  teeth,  are  among  the 
consequences  that  result  from  it.  But  besides  these,  other  effects  are 
occasionally  produced,  among  which  may  be  enumerated  tumors  and 
spongy  excrescences  of  the  gums  of  various  kinds,  necrosis  and  ex- 
foliation of  the  alveolar  processes  and  of  portions  of  the  maxillary 
bones,  hemorrhage  of  the  gums,  anorexia,  derangement  of  the  whole 
digestive  apparatus,  and  foul  breath,  catarrh,  cough,  diarrhoea,  diseases 
of  various  kinds  in  the  maxillary  antra  and  nose,  pain  in  the  ear, 
headache,  melancholy,  hypochondriasis,  etc.  So  irritating  is  its  pres- 
ence that,  wherever  it  comes  in  contact  with  the  gums  and  alveoli,  it 
causes  their  absorption,  which  in  some  cases  may,  at  first,  be  attended 
with  little  or  no  inconvenience  to  the  parties ;  while  in  others  consider- 
able inflammation,  ending  in  suppuration  of  the  gums,  may  result,  ex- 
tending to  the  mucous  membrane  of  the  mouth.  Periostitis  and  necrosis 
of  the  alveolar  processes  are  also  results  of  the  irritating  action  of  this 
substance.  The  character  of  the  effects,  however,  both  local  and  con- 
stitutional, depends  upon  the  quantity  and  consistence  of  the  tartar, 
and  upon  the  temperament  of  the  individual  as  well  as  the  state  of  the 
general  health ;  the  two  former  of  these  are  determined  by  the  two 
latter,  and  by  the  attention  paid  to  the  cleanliness  of  the  teeth.  If 
this  last  be  properly  attended  to,  salivary  calculus,  no  matter  how 
great  the  constitutional  tendency  to  its  formation,  will  not  collect  in 
large  quantity  upon  the  teeth.  The  importance,  therefore,  of  its  con- 
stant observance  cannot  be  too  strongly  impressed  upon  the  patient. 


SALIVARY   CALCULUS.  249 

especially  in  those  in  whom  there  exists  a  great  tendency  to  its 
deposition. 

The  teeth  and  their  contiguous  parts  suffer  more  from  accumulations 
of  this  substance,  than  almost  any  other  cause.  Caries  is  not  much 
more  destructive  to  them.  When  permitted  to  accumulate  for  any 
great  length  of  time,  the  gums  become  so  morbidly  sensitive  that  a 
tooth-brush  cannot  be  used  without  causing  pain ;  consequently,  the 
cleanliness  of  the  mouth  is  not  attempted,  and  thus,  no  means  being 
taken  to  prevent  its  formation,  it  accumulates  with  increased  rapidity, 
until  the  teeth,  one  after  another,  fall  in  quick  succession  victims  to  its 
desolating  ravages. 

It  sometimes  not  only  undermines  the  constitution,  by  occasioning 
discharges  of  fetid  matter  from  the  gums,  and  corrupting  the  fluids  of 
the  mouth,  but  it  also  renders  the  breath  exceedingly  unpleasant  and 
offensive.  So  nauseating  and  disagreeable  is  the  odor  which  some 
descriptions  of  tartar  exhale,  that  the  atmosphere  of  a  whole  room  is 
contaminated  by  it  in  a  few  minutes. 

IVLiNNER   OF    REMOVING   SALIVARY   CALCULUS. 

This  is  an  operation  of  great  importance  to  the  health  of  the 
gums,  alveolar  processes,  and  teeth.  But  from  a  misconception  of 
its  nature,  rather  than  from  fear  of  pain,  many  are  much  opposed 
to  it ;  and,  notwithstanding  the  universal  admiration  in  which  clean 
and  white  teeth  are  held,  they  will  suffer  the  beauty  of  these  organs 
to  be  destroyed  rather  than  submit  to  its  performance.  There  are 
some,  indeed,  who,  though  scrupulously  particular  in  everything  that 
regards  dress,  seem  nevertheless  to  consider  cleanliness  of  the  mouth 
as  unworthy  of  notice. 

For  the  removal  of  tartar  from  the  teeth,  a  variety  of  instruments 
are  necessary,  which  should  be  so  constructed  that  they  may  be  easily 
applied  to  every  part  of  every  tooth.  Those  in  common  use  among 
dental  practitioners  are  so  very  similar  in  their  shape  and  so  well 
known,  that  we  do  not  deem  it  necessary  to  point  out  the  minute 
differences  of  construction,  or  even  to  give  a  general  description  of  the 
instruments  themselves.  The  instruments  should  be  light,  made  with 
ivory,  ebony,  or  cocoa  handles,  and  tapering  from  a  little  above  the 
ferule,  both  ways ;  and  the  points  of  the  instruments  should  be  deli- 
cately shaped,  so  as  readily  to  pass  below  the  free  edge  of  the  gum. 
The  success  of  the  operation  depends  much  upon  the  careful  removal 
of  every  particle  of  deposit;  for  which  a  heavy,  clumsy,  or  large-bladed 
instrument  is  wholly  unsuited.  If  any  particles  of  tartar  be  suffered 
to  remain,  they  will  irritate  the  gums,  and  serve  as  nuclei  for  immediate 
re-accumulations. 


250 


DENTAL   PATHOLOGY,  THERAPEUTI()S. 


Drs.  F.  Abbott's  and  G.  Cushing's  sets  of  scalers,  represented  in  the 
following  figures,  are  well  adapted  for  removing  salivary  calculus  from 
all  parts  of  the  teeth. 

Fig.  89. 


Fig.  90. 


The  adhesion  of  tartar  to  the 
teeth  is  sometimes  so  great  that 
considerable  force  is  required  for 
its  removal,  even  when  the  sharp- 
est and  best-tempered  instru- 
ments are  employed ;  but  ordi- 
narily it  may  be  removed  with 
ease.  Considerable  tact,  how- 
ever, is  necessary  to  perform  the 
operation  in  a  skillful  manner ; 
more  than  most  persons,  from 
its  apparent  simplicity,  imagine.  This  skill  can  only  be  acquired  by 
practice.  Tartar  may  be  taken  from  the  outer  and  inner  surfaces  of 
the  teeth  without  much  difficulty ;  but  the  removal  of  it  from  between 
them  is  more  troublesome,  and  can  only  be  effected  by  means  of  very 
thin,  sharjD-pointed  instruments. 

In  removing  this  substance  from  the  teeth,  the  point  or  edge  of  the 
scaling  instrument  should  be  applied  below  the  deposit,  between  it  and 
the  gum,  and  passed  well  under,  until  it  comes  in  contact  with  the  sur- 
face of  the  tooth,  and  the  mass  scaled  off  in  the  direction  of  the  cutting 
edge  or  grinding  surface. 

Care  is  necessary  that  the  edge  of  the  instrument  does  not  roughen 
the  tooth  substance,  especially  the  dentine,  beyond  the  enamel ;  and  to 
prevent  the  possibility  of  this,  some  recommend  the  use  of  instruments 
from  which  the  sharp  edge  has  been  removed.  After  the  removal  of 
the  greater  part  of  the  deposit,  the  instrument  should  be  lightly  passed 


SANGUINARY   CALCULUS.  251 

over  the  surface,  to  detach  any  particles  which  may  remain,  especially 
upon  the  approximal  surfaces.  After  the  use  of  the  scaling  instruments, 
finely  pulverized  pumice  or  silex  should  be  applied  on  a  piece  of  orange 
wood  so  shaped  as  to  reach  all  parts  on  which  the  deposit  has  collected. 
Where  the  surface  of  the  enamel  or  dentine  is  found  to  be  rough  and 
without  the  natural  polish,  after  the  use  of  the  pumice  or  silex,  Arkan- 
sas stone  and  the  burnisher  may  be  applied  with  advantage  and  a  finely 
polished  surface  obtained. 

Several  sittings  are  sometimes  necessary  for  the  completion  of  the 
operation,  especially  when  the  tartar  has  accumulated  in  very  large 
quantities.  In  all  cases  of  this  sort,  it  should  be  first  removed  from 
between  the  edges  of  the  gums  and  the  necks  of  the  teeth.  During  the 
intervals  between  the  several  operations  the  mouth  should  be  gargled, 
several  times  a  day,  with  some  cooling  and  astringent  wash ;  but  on 
this  subject  more  particular  directions  will  be  given  in  another  chapter. 

During  the  removal  of  tartar  from  the  teeth,  the  gums  often  bleed 
very  freely  ;  and  when  much  swollen  and  spongy,  it  may  be  well  to 
promote  it  by  holding  tepid  water  in  the  mouth.  When  the  lower 
incisors  are  loose,  as  is  often  the  case,  the  operation  should  be  pro- 
ceeded with  very  cautiously,  and  the  teeth  supported  by  the  fingers  of 
the  left  hand  holding  the  jaw,  especially  when  the  tartar  is  very  hard 
and  adheres  with  great  tenacity. 

The  wood-points  of  various  forms,  charged  with  finely-powdered 
pumice  or  silex,  and  rotated  by  means  of  the  dental  engine,  are  very 
useful  for  removing  the  discoloration  caused  by  salivary  calculus  and 
the  dark  mucous  deposit,  which  often  cause  the  teeth  to  present  quite 
an  unsightly  appearance. 

Chemical  agents  are  sometimes  employed  for  the  removal  of  salivary 
calculus,  especially  such  of  the  vegetable  and  mineral  acids  as  are 
supposed  to  have  less  afiinity  for  the  lime  of  the  teeth  than  the  phos- 
phoric acid  with  which  it  is  combined  ;  but  it  is  scarcely  necessary  to 
say  that  any  acid  capable  of  dissolving  tartar  will  act  upon  these 
organs.  The  use  of  all  such  agents  should  be  most  scrupulously 
avoided.  Nearly  all  acids,  both  mineral  and  vegetable,  as  has  been 
shown  in  another  part  of  this  work,  are  prejudicial  to  the  teeth. 
Their  careless  administration  by  physicians  is  a  fruitful  source  of 
injury  to  the  teeth.  And  they  certainly  should  form  no  part  of  any 
dentrifice,  or  be  in  any  way  used  for  the  removal  of  stains  of  any  kind 
from  the  teeth. 

SANGUINARY    CALCULUS. 

By  this  title  Dr.  L.  C.  IngersoU  designates  a  structureless  calcareous 
deposit  found  at  the  apex  of  the  root  of  a  tooth,  or  sometimes  extend- 
ing in  a  line  of  granules  along  the  root  from  the  apex  to  the  neck  of  the 


252  DENTAL  PATHOLOGY,  THERAPEUTICS. 

tooth,  or  again  encircling  the  root  immediately  beneath  the  free  margin 
of  the  gum.  Being  of  a  sanguinary  origin,  it  is  found  only  where  the 
serum  of  the  blood  is  present,  which,  being  decomposed,  gives  up  its 
lime  salts,  and  affords  material  for  the  deposit,  which  is  stained  with 
the  hematin  of  the  blood.  This  form  of  calculus  is  the  result  of  ulcer- 
ation, and  its  superior  hardness  is  due  to  its  being  more  purely  mineral 
than  salivary  calculus,  and  it  is  generally  of  a  black  or  dark-green  color. 
Sanguinary  calculus  is  deposited  upon  the  roots  of  the  teeth,  and  not 
upon  their  crowns,  as  with  salivary  calculus,  being  often  found  upon  the 
very  apex  of  the  roots.  It  also  differs  in  another  respect  from  salivary 
calculus  ;  the  sanguinary,  resulting  from  the  disorganization  of  blood, 
and  ulceration  of  tissues,  is  in  the  form  of  dark,  hard  granulations  ap- 
proaching crystallization.  The  root  of  the  affected  tooth  is  denuded  of 
its  cementura,  and  the  granular  deposit  so  closely  adheres  that  its  re- 
moval is  quite  difficult.  Sometimes  it  is  found  immediately  beneath 
the  margin  of  the  gum,  in  the  form  of  a  dark,  hard,  rough  ring,  which 
may  occasionally  be  visible  through  the  gum,  in  the  form  of  a  dark 
circle.  A  viscid,  serous  fluid  may  exude  from  about  the  neck  of  the 
toott  under  slight  pressure,  the  result  of  the  ulceration  which  gives 
rise  to  the  deposit.  This  fluid  is  not  of  the  same  nature  as  the  pus  from 
an  abscess,  being  watery  and  nearly  odorless,  and  composed,  in  a 
great  part,  of  the  serum  of  the  blood.  While  salivaiy  calculus  causes 
inflammation,  sanguinary  calculus  is  a  result  of  inflammatory  action, 
and  is  found  upon  teeth  affected  with  ulcei-ation. 

MUCOUS   DEPOSIT   OIST   THE   TEETH. 

While  persons  of  all  ages  are  subject  to  deposits  of  salivary  calculus, 
there  is  a  mucous  deposit,  to  which  the  teeth  of  children  are  especially 
liable,  in  the  form  of  a  brown  or  a  green  stain,  which  has  been  erro- 
neously called  green  tartar.  This  deposit  is  generally  found  upon  the 
labial  surfaces  of  the  front  teeth,  more  especially  upon  those  of  the  upper 
jaw,  and  varies  in  color  from  a  light  brown  to  a  dark  green.  From  its 
not  collecting  upon  the  posterior  teeth  and  upon  the  lingual  surfaces 
of  the  inferior  front  teeth  opposite  the  mouths  of  the  ducts  leading  from 
the  salivary  glands,  there  is  every  reason  to  conclude  that  this  deposit 
is  not  precipitated  by  the  saliva,  and  hence  is  altogether  different  in  its 
origin  from  salivary  calculus.  It  is  generally  considered  to  be  a  de- 
posit from  the  mucus,  when  this  secretion  is  in  a  more  acid  condition 
than  is  natural.  From  its  effects  upon  the  teeth,  when  it  is  allowed  to 
remain  on  them  for  a  considerable  time,  and  also  from  the  fact  that  it 
is  most  abundant  when  the  mucus  is  secreted  in  large  quantities  and 
of  a  decidedly  acid  reaction,  there  is  little  doubt  as  to  its  origin  from 
this  secretion. 


MUCOUS    DEPOSIT    ON    THE    TEETH.  253 

That  it  is  not  deposited  on  all  parts  of  the  teeth,  is  no  reason  for 
doubting  the  correctness  of  this  theory,  when  we  consider  that  the  parts 
up.)n  which  it  is  found  are  those  protected  from  the  friction  of  food  and 
the  movements  of  the  tongue  and  the  flow  of  the  saliva. 

In  regard  to  the  effects  of  this  mucous  deposit  upon  the  teeth,  while 
salivary  calculus  tends  to  preserve  the  portion  of  tooth  substance  on 
which  it  is  precipitated,  this  green  stain  so  erodes  the  enamel  that  de- 
cay advances  in  the  part  which  it  covers,  more  or  less  rapidly,  accord- 
ing to  the  quality  of  the  teeth  and  the  length  of  time  it  is  allowed  to 
remain.  The  removal  of  this  mucous  deposit  requires  more  skillful 
manipulation  than  that  of  salivary  calculus,  on  account  of  its  being  a 
thin  film  entering  into  the  substance  of  the  enamel,  rendering  it  diffi- 
cult to  detach  without  injury  to  the  tooth  substance  ;  whereas  salivary 
calculus  is  deposited  in  such  quantities  as  to  leave  thick  incrustations, 
which  are  readily  scaled  off  from  an  uninjured  surface.  Where  the 
erosion  caused  by  this  mucous  deposit  is  but  slight,  it  may  be  removed 
by  Arkansas  or  Superior  stones,  or  by  finely  powdered  silex  or  pumice 
stone  and  water  applied  on  a  stick  of  hard,  fine-grained  wood,  such  as 
orange  wood  or  hickory ;  the  point  of  the  piece  of  wood  being  so 
formed  as  to  adapt  it  well  to  the  surface  on  which  it  is  to  be  used. 
The  wood-points  charged  with  either  of  the  powders  referred  to,  and 
rotated  by  means  of  the  dental  engine,  will  prove  very  serviceable 
for  such  an  operation.  After  all  the  discoloration  is  removed  by  the 
means  just  referred  to,  the  surface  should  be  well  burnished  with  a 
steel  burnisher  and  a  solution  of  pure  Castile  or  white  Windsor  soap. 
When,  however,  the  effects  of  this  mucous  deposit  are  more  serious,  the 
enamel  not  only  being  discolored  but  deeply  eroded,  it  is  necessary  to 
make  use  of  the  corundem  point,  rotated  by  means  of  the  dental 
engine,  the  enamel  chisel  or  file,  to  remove  the  injured  surface.  The 
enamel  chisel  is  to  be  preferred  to  the  file  in  all  cases  where  it  is 
applicable ;  and  the  plain  surface  thus  obtained  should  be  polished 
with  fine  silex  or  pumice  stone,  Arkansas  or  Superior  stones,  and  the 
burnisher.  Care  is  necessary  in  the  use  of  the  enamel  chisel,  to  avoid 
wounding  the  neighboring  soft  tissues.  To  prevent  the  possibility  of 
such  an  accident,  and  to  enable  the  operator  to  have  control  over  his 
instrument,  the  chisel  should  be  held  firmly  with  the  hand  in  such  a 
manner  as  to  allow  the  thumb  to  rest  on  an  adjoining  tooth.  When 
the  dentine  is  very  sensitive,  as  is  frequently  the  case,  a  proper  agent 
for  allaying  the  sensitiveness  may  be  applied  from  time  to  time  to  the 
surface,  as  the  operation  of  cutting  it  away  proceeds.  (See  "  Treat- 
ment of  Sensitive  Dentine.") 


254  DENTAL  PATHOLOGY,  THERAPEUTICS. 


CHAPTER  VII. 

THE    FLUIDS   OF   THE   MOUTH. 

IN  treating  upon  the  physical  characteristics  of  the  fluids  of  the 
mouth,  it  will  not  be  necessary  to  dwell  at  much  length  on  their 
efiects,  when  in  a  morbid  condition,  on  this  cavity.  Concerning  their 
ao-ency  in  the  production  of  caries  of  the  teeth,  we  shall  add  one  or 
two  remarks. 

Saliva,  in  healthy  persons  having  good  constitutions,  has  a  light 
frothy  appearance,  and  but  little  viscidity.  Inflammation  of  the  gums, 
from  whatever  cause  produced,  increases  its  viscidity,  and  causes  it  to 
be  less  frothy.  In  a  healthy  state,  it  is  inodorous,  floats  upon  and 
mixes  readily  with  water,  but  when  in  a  viscid  or  diseased  condition, 
it  sinks  and  mixes  with  it  with  difficulty. 

Irritation  in  the  mouth,  from  diseased  gums,  aphthous  ulcers,  in- 
flammation of  the  mucous  membrane,  the  introduction  of  mercury 
into  the  system,  or  taking  anything  pungent  into  the  mouth,  increases 
the  flow  of  this  fluid,  and  causes  it  to  be  more  viscid  than  it  is  in  its 
natural  and  healthy  state. 

In  treating  on  the  symptomatology  of  saliva.  Prof  Schill  says,  "  The 
sympathetic  affection  of  the  stomach  in  pregnancy  is  sometimes  ac- 
companied by  salivation,  w^iich,  in  this  case,  mostly  takes  place  after 
conception,  and  sometimes  continues  to  the  time  of  delivery.  It  is 
also  observed  to  occur  in  weakened  digestion,  in  gastric  catarrhs,  after 
the  use  of  emetics,  in  mania,  in  what  are  called  abdominal  obstruc- 
tions, in  hypochondriasis  and  hysteria ;  salivation  occurs  during  the 
use  of  mercury  or  antimony. 

"  In  confluent  smallpox,  salivation  is  a  favorable  sign.  If  it  cease 
before  the  ninth  day,  the  prognosis  is  bad.  In  lingering  intermittents, 
salivation  is  sometimes  critical ;  more  frequently  in  these  affections  it 
precedes  the  termination  in  dropsy. 

"  Diminution  of  the  salivary  secretion,  and,  in  consequence  of  this, 
dryness  of  the  mouth,  is  peculiar  to  the  commencement  of  acute 
disease,  as  also  to  the  hectic  fevers  occasioned  by  affections  of  the 
abdominal  organs.  If  the  flow  of  the  saliva  stop  suddenly,  there  is 
reason  to  apprehend  an  affection  of  the  brain. 

"  Thick,  viscid  saliva  occurs  under  the  same  circumstances  as  the 
diminution  of  the  salivary  secretion,  especially  in  smallpox,  typhus, 
and  in  hectic  fevers.    It  is  thin  in  ptyalism.    In  gastric  diseases,  where 


THE   FLUIDS   OF   THE   MOUTH.  255 

the  liver  participates,  it  becomes  yellow  or  green ;  by  the  admixture 
of  blood  it  may  assume  a  reddish  color;  in  pregnant  or  lying-in 
women,  it  is  sometimes  milky;  an  icy  cold  saliva  was  observed  by  the 
author  in  face-ache. 

"  Frothy  saliva  from  the  mouth  is  observed  in  apoplexy,  epilepsy, 
hydrophobia,  and  in  hysterical  paroxysms." 

Dr.  Bell,  of  Philadelphia,  in  a  note  to  the  work  from  which  we 
have  just  quoted,  says,  "Acid  saliva  is  regarded  by  M.  Donne  as 
indicative  of  gastritis  or  deranged  digestion.  Mr.  Laycock,"  he 
observes,  "  on  the  other  hand,  infers  from  numerous  experiments 
on  hospital  patients  that  the  saliva  may  be  acid,  alkaline,  or  neutral, 
when  the  gastric  phenomena  are  the  same.  In  general,  Mr.  L.  re- 
marked that  it  was  alkaline  in  the  morning  and  acid  in  the  evening." 

"We  have  had  occasion  to  observe  that  the  acid  quality  of  the 
saliva  was  more  apparent  and  more  common  in  lymphatic,  mucous 
and  bilious  dispositions,  than  in  sanguineous  or  in  sauguineo-serous 
persons,  and  that  weakened  or  impaired  digestion  always  had  a 
tendency  to  increase  it. 

M.  Delabarre  says,  "When  this  fluid"  (the  saliva*  "has  remained 
in  the  mouth  some  moments,  it  there  obtains  new  properties,  accord- 
ing to  each  individual's  constitution  and  the  integrity  of  the  mucous 
membrane,  or  some  of  the  parts  which  it  covers. 

"  In  subjects  who  enjoy  the  best  health,  whose  stomach  and  lungs 
are  uninjured,  the  saliva  appears  very  scarce,  but  this  is  because  it 
passes  into  the  stomach  almost  as  soon  as  it  is  furnished  by  the  glands 
that  secrete  it.  It  only  remains  long  enough  in  the  mouth  to  mix  with 
a  small  quantity  of  mucus,  and  absorb  a  certain  portion  of  atmospheric 
air,  to  render  it  frothy. 

"  On  the  other  hand,  the  saliva  of  an  individual  whose  mucous  system 
furnishes  a  large  quantity  of  mucus,  is  stringy  and  heavy  ;  is  but 
slightly  charged  with  oxygen,  contains  a  great  portion  of  azote  and 
sulphur,  and  stains  silver." 

Increased  redness  and  irritability  of  the  mucous  membrane  of  the 
mouth  is  an  almost  invariable  accompaniment  of  general  acidity  of 
these  fluids.  Excoriation  and  aphthous  ulcers,  and  bleeding  of  the 
gums,  also,  frequently  result  from  this  condition  of  the  salivary  and 
mucous  secretions  of  this  cavity. 

Anorexia,  languor,  general  depression  of  spirits,  headache,  diarrhoea, 
and  rapid  decay  of  the  teeth,  are  very  common  among  persons  habitu- 
ally subject  to  great  viscidity  of  the  buccal  fluids.  It  is  likewise  among 
subjects  of  this  kind,  and  particularly  when  the  viscidity  is  so  great  as 
to  cause  clamminess  of  these  secretions,  that  the  green  discoloration  of 
the  enamel  of  the  teeth  is  most  frequently  met  with. 


256  DENTAL   PATHOLOGY,  THEEAPEUTICS. 


CHAPTER  VIII. 

CHARACTERISTICS    OF   THE    LIPS. 

THE  indications  of  the  physical  characteristics  of  the  lips  are  more 
general  than  local,  and  the  observations  of  Laforgue  and  Delabarre 
on  this  subject  leave  little  to  be  added.  We  cannot,  therefore,  do  much 
more  than  repeat  what  they  have  said. 

"  The  lips,"  says  Delabarre,  "  present  marked  difference  in  different 
constitutions.  They  are  thick,  red,  rosy,  or  pale,  according  to  the 
qualities  of  the  blood  that  circulates  through  their  arteries." 

Firmness  of  the  lips,  and  a  pale  rose  color  of  the  mucous  membrane 
that  covers  them,  are,  according  to  Laforgue,  indicative  of  pure  blood, 
and,  as  a  consequence,  of  a  good  constitution.  Redness  of  the  lips, 
deeper  than  that  of  the  pale  rose,  is  also  mentioned  as  one  of  the  signs 
of  sanguineo-serous  blood.  Soft,  pale  lips  are  indicative  of  lymphatico- 
serous  dispositions.  In  those  subjects  the  lips  are  almost  entirely  with- 
out color.  "When  there  is  a  sufficiency  of  blood,  the  lips  are  firm,  though 
variable  in  color,  according  to  the  predominancy  of  the  red  or  serous 
parts  of  this  fluid. 

Both  hardness  and  redness  of  the  lips,  and  all  the  soft  parts  of  the 
mouth  are  enumerated  among  the  signs  of  plethora.  Softness  of  the 
lips,  without  change  of  color  in  their  mucous  membrane,  is  spoken  of 
by  the  last  author  as  indicative  of  deficiency  of  blood  ;  and  softness 
and  redness  of  the  mucous  membrane  of  the  lips  are  signs  that  the  blood 
is  small  in  quantity  and  sanguineo-serous. 

Deficiency  in  the  red  corpuscles,  and  in  the  nutritive  qualities  of  the 
blood,  is  evidenced  by  the  want  of  color  and  softness  of  the  lips,  and 
general  paleness  of  the  mucous  membrane  of  the  whole  mouth.  "  The 
fluids  contained  in  the  vessels,"  says  Laforgue,  "  in  forms  of  ansemia, 
yield  to  the  slightest  pressure,  and  leave  nothing  between  the  fingers 
but  the  skin  and  cellular  tissue." 

In  remarking  upon  the  signs  of  the  different  qualities  of  the  blood, 
the  above-mentioned  author  asserts  that  the  constitution  of  children 
about  six  years  of  age  cannot  be  distinguished  by  any  universal  char- 
acteristics ;  but  that  the  lips,  as  well  as  the  other  parts  of  the  mouth, 
constantly  betoken  "  the  quality  of  blood  and  that  of  the  flesh  ;"  and, 
"  consequently  they  proclaim  health  or  disease,  or  the  approach  of 
asthenic  and  adynamic  disorders,  which  the  blood  either  causes  or 
aggravates." 


CHARACTERISTICS   OF   THE   LIPS.  257 

Again,  he  observes  that  the  blood  of  all  children  is  "  superabund- 
antly serous,"  but  that  it  is  redder  in  those  of  the  second  constitution 
than  in  those  of  any  of  the  others,  and  that  this  is  more  disthictly 
indicated  by  the  color  of  the  lips.  "  The  quality  of  the  blood,"  says 
he,  "  is  necessary  to  dispose  all  the  parts  to  elongate  in  their  growth. 
AVhen  the  proportions  of  the  constituent  elements  of  the  blood  are 
just,  growth  is  accomplished  without  disease.  If  the  proportions  are 
otherwise  than  they  should  be  for  the  preservation  of  the  health,  or  if 
one  or  more  of  its  elements  be  altered,  health  no  longer  exists,  growth 
is  arrested  altogether,  or  is  performed  irregularly.  The  nutritive 
matter  is  imperfect,  assimilation  is  prevented  or  impaired.  On  the 
other  hand,  its  disintegration  decomposes  the  patient ;  if  death  does 
not  sooner  result,  it  will  consume  him  by  the  lesion  of  some  vital 
organ." 

The  changes  produced  in  the  color  of  the  blood  by  organic  derange- 
ment are  at  once  indicated  by  the  color  of  the  lips. 

The  accuracy  of  Laforgue's  observations  on  the  indications  of  the 
physical  characteristics  of  the  lips  has  been  fully  confirmed  by  subse- 
quent writers. 

"  The  secretion  of  the  lips,"  says  Prof.  Schill,  "  has  a  similar 
diagnostic  and  prognostic  import  to  that  of  the  tongue  and  gums. 
They  become  dry  in  all  fevers  and  in  spasmodic  paroxysms.  A 
mucous  white  coating  is  a  sign  of  irritation  or  inflammation  of  the 
intestinal  canal;  accordingly,  this  coating  is  found  in  mucous  ob- 
structions, in  gastric  and  intermittent  fevers,  in  mucous  fever,  and 
before  a  gouty  paroxysm.  A  dry,  brown  coating  of  the  lips  is  a  sign 
of  colliquation  in  consequence  of  typhus  affections ;  it  is  accordingly 
observed  in  typhus,  in  putrid  fever,  in  acute  exanthemata,  and 
inflammations  which  have  become  nervous." 

The  lips,  however,  do  not  present  so  great  a  variety  of  appearance 
as  those  of  other  parts  of  the  mouth,  for  the  reason  that  they  are 
not  as  subject  to  local  diseases  ;  but  their  general  pathological  indica- 
tions are,  perhaps,  quite  as  decided. 


17 


258  DENTAL  PATHOLOGY,  THERAPEUTICS. 


CHAPTER  IX. 

CHARACTERISTICS   OF   THE   TONGUE. 

THE  appearance  of  the  tongue,  both  in  health  and  disease,  is  re- 
garded by  physicians  as  furnishing  more  correct  indications  of  the 
state  of  the  constitution  and  general  health  than  any  of  the  other  parts 
of  the  mouth.  It  is  asserted,  however,  by  others,  and  by  those,  too, 
who  have  the  very  best  opportunities  for  inspecting  the  various  parts 
of  this  cavity,  that  the  lips  and  gums  furnish  as  marked  and  reliable 
indications  as  the  tongue.  That  the  state  and  quality  of  the  blood 
can  be  as  readily  ascertained  by  an  examination  of  these  parts  as  by 
that  of  the  tongue,  is,  we  believe,  undeniable ;  but  that  the  patho- 
logical condition  of  the  body  can  be  inferred  is  a  question  we  leave 
for  others  to  decide. 

So  far  as  the  quality  of  the  blood  and  the  temperament  of  the  sub- 
ject are  indicated  by  the  color  of  the  tongue,  the  preceding  remarks 
concerning  the  lips  will  be  found  applicable,  the  one  being  as  much 
influenced  by  them  as  the  other.  It  will,  therefore,  be  unnecessary  to 
recapitulate  what  we  have  before  said  upon  the  subject. 

The  effects  produced  upon  the  mucous  membrane  of  the  tongue  by 
disease  in  any  other  part,  are  said  to  be  analogous  to  those  produced 
on  the  general  integument.  So,  also,  are  the  changes  of  its  color, 
consistence,  humidity  and  temperature,  similar  to  those  of  the  skin. 
We  are  likewise  told  that  the  changes  of  its  coating  agree  with  the 
analogous  changes  of  the  perspiration,  and  that  these  phenomena  are 
more  decided  in  acute  than  in  chronic  affections. 

But  the  diagnostic  and  prognostic  indications  of  the  tongue  vary 
according  to  the  temperament  and  constitutional  predisposition  of  the 
individual.  The  physician  should  acquaint  himself  with  its  appear- 
ances in  health,  to  be  able  to  determine  correctly  its  indications  in 
disease.  He  should  likewise  inform  himself  of  the  changes  produced 
in  its  appearance  by  certain  morbid  conditions  of  the  body.  In  some 
subjects  it  is  always  slightly  furred  and  rather  dry,  especially  near  its 
root ;  in  others  it  is  always  clean  and  humid ;  in  some,  again,  it  is 
always  red,  and  in  others  pale. 

Prof.  Schill  divides  the  signs  of  the  tongue  into  objective  and  sub- 
jective. "  To  the  objective  belong  the  changes  of  size,  form,  consist- 
ence, color,  temperature,  secretion,  and  of  power  and  direction  of  motion; 
and  to  the  subjective  belong  the  anomalous  sensations  of  taste." 


CHARACTERISTICS   OF   THE   TONGUE.  259 

In  enumerating  the  pathognomonic  signs  of  the  tongue,  this  author 
says  that  hypertrophy,  inflammation  or  congestion,  may  occasion  its 
enlargement ;  and  that  inflammatory  swelling  of  it,  when  arising  from 
acute  diseases,  such  as  "angina,  pulmonary  inflammation,  measles, 
plague,  or  variola,  yields  an  unfavorable  prognosis.  Even  non-in- 
flammatory swelling  of  the  tongue  is  a  dangerous  phenomenon  in  acute 
diseases,  especially  cerebral,  which  are  combined  wdth  coma.  If  it  be 
the  consequence  of  mercury,  of  the  abuse  of  spirituous  drinks,  of 
gastric  inflammation,  of  chlorosis,  of  syphilis,  or  if  it  occur  in  hysteria 
or  epilepsy,  the  prognosis  is  not  dangerous ;  but  the  disease  is  always 
the  more  tedious  where  the  tongue  swells  than  where  it  does  not. 
It  is  enlarged,  also,  by  degenerescence  and  cancer. 

"  Diminution  of  the  size  of  the  tongue  takes  place  where  there  is 
considerable  emaciation.  In  this  case  it  continues  soft  and  movable. 
If,  in  acute  states,  the  tongue  becomes  small,  and  is,  at  the  same 
time,  hard,  retracted  and  pointed,  the  irritation  is  very  great  and  the 
prognosis  bad.  This  sign  occurs  more  especially  in  typhus,  in  the 
oriental  cholera,  in  inflammation  of  the  lungs,  and  in  acute  cerebral 
affections.  In  hysteria  and  epilepsy  this  phenomenon  has  no  unfavor- 
able import." 

Internal  maladies,  he  says,  seldom  cause  the  form  of  the  tongue  to 
change ;  but  that  the  simplest  change  arising  from  chronic  irritations 
of  the  stomach,  chronic  dyspepsia,  and  acute  exanthemata,  is  enlarge- 
ment of  its  papillee.  In  cases  of  protracted  dyspepsia,  the  edges  of 
the  tongue  sometimes  crack,  and  in  paralysis  and  epilepsy  it  becomes 
elongated. 

In  acute  diseases,  a  soft  tongue  is  a  favorable  indication;  and 
flaccidity  of  it  is  symptomatic  of  debility. 

Humidity  of  the  tongue,  he  tells  us,  is  a  favorable  sign,  and  that 
dryness  of  it  occurs  in  acute  or  violent  inflammations  and  irritations, 
and  more  particularly  when  seated  in  the  intestinal  canal  and  respira- 
tory organs.  "  This  also  happens  in  diarrhoea,  typhus,  pneumonia, 
gangrene  of  the  lung,  pleuritis,  peritonitis,  enteritis,  catarrhus  gas- 
tricus,  gastritis,  inflammation  of  joints,  etc.  Among  the  higher  deo-rees 
of  dryness  he  enumerates  the  rough,  the  fissured  and  burnt  tongue  as 
furnishing  still  more  unfavorable  indications,  informing  us,  at  the  same 
time,  that  if  these  be  not  accompanied  by  thirst,  they  prognosticate  a 
fatal  termination.  The  abatement  and  crisis  of  the  disease  is  indicated 
by  the  tongue  becoming  moist." 

Dr.  Bell,  of  Philadelphia,  in  a  note  to  Prof  Schill's  observations  on 
the  tongue,  says,  "  A  rough  and  dry,  and  even  furred  tongue  is  seen 
in  some  dyspeptic  persons  who  sleep  with  the  mouth  open ;  and  -al- 
though it  indicates  an  irritation  of  the  digestive  organs,  it  is  not  a  bad 


260  DENTAL  PATHOLOGY,  THERAPEUTICS. 

augury."  Bilious  persons,  not  unfrequently,  though  not  troubled  with 
any  manifest  symptoms  of  gastric  or  intestinal  derangement,  or  any 
other  apparent  functional  disturbance,  have  a  furred  tongue  in  the 
morning. 

Paleness  of  the  tongue,  says  Prof  Schill,  is  a  sign  of  a  serous  con- 
dition of  the  blood,  of  chlorosis,  of  great  loss  of  blood,  of  chronic  dis- 
orders, of  sinking  of  the  strength  in  acute  maladies  assuming  a 
"  nervous  foi-m,  as  typhus  and  scarlatina  maligna.  It  is  also  found," 
says  he,  "  in  enteritis  and  dysentery,  when  but  little  fever  is  present." 
He  infers  from  this  that  paleness  of  the  tongue  is  caused  by  the 
"  draAving  of  the  fluid  downward  ;"  but  it  is  often  observed  in  persons 
who  enjoy  tolerably  good  health.  Lymphatic  dispositions,  as  has  been 
before  remarked,  are  peculiarly  subject  to  it. 

•  Again  he  observes  that  a  very  red  tongue  is  indicative  of  "  violent 
inflammation,  mostly  of  the  intestinal  canal,  but  also  of  the  lungs  and 
pharynx,  also  of  acute  exanthemata.  He  regards  the  prognosis  as  bad, 
when  a  furred  tongue,  "  in  acute  diseases  of  the  intestinal  canal,  becomes 
clean  and  very  red,"  if  the  change  is  not  accompanied  with  the  return 
of  the  patient's  strength.  ""But,"  he  continues,  "if  the  debility  is  not 
considerable,  and  the  tongue  becomes  clean  and  very  red  while  other 
febrile  symptoms  continue,  a  new  inflammation  may  be  expected." 
But  even  in  affections  like  these,  the  redness  of  the  tongue  is  always 
more  considerable  in  sanguineous  than  in  lymphatic  or  lymphatico- 
serous  subjects,  so  that  in  forming  a  prognosis  from  this  sign,  the  tem- 
perament of  the  individual  should  never  be  overlooked." 

Proceeding  with  the  description  of  the  signs  of  this  organ,  he  says, 
"  The  tongue  becomes  a  blackish-red  and  bluish-red  in  all  serious  dis- 
turbances of  the  circulation  and  respiration,  as  also  in  severe  diseases 
of  the  lungs  and  heart,  as  catarrhs,  suffocations,  asthma,  extensive 
inflammations  of  the  lungs,  carditis,  Asiatic  cholera,  confluent  smallpox, 
and  putrid  fevers.  It  becomes  black  and  livid  in  cases  of  vitiation  of 
the  blood,  more  especially  in  scurvy,  at  the  setting  in  of  gangrene,  and 
in  phthisis,  when  death  is  near  at  hand." 

Among  the  diseases  mentioned  as  giving  rise  to  an  increase  of  the 
temperature  of  the  tongue,  are  glossitis,  violent  internal  inflammation, 
and  typhus  fever ;  and  coldness  of  this  organ  is  observed  to  take  place 
in  Asiatic  cholera,  and  at  the  approach  of  death. 

The  signs  from  the  secretion  of  the  tongue  are  thus  enumerated :  A 
clean  and  moist  tongue  are  favorable  indications,  but  a  clean,  dry  and 
red  tongue,  as  seen  in  slow,  nervous  fevei's,  acute  exanthemata  and 
plague,  are  bad  auguries.  A  furred  or  coated  tongue  is  said  to  occur 
chiefly  in  intestinal  disorders,  diseases  of  the  lungs,  skin,  and  in 
rheumatic  affections.     The  coating  is  said  to  vary  in  "  color,  thickness. 


CHARACTERISTICS    OF    THE    TOXGUE.  26 1 

adherence,  and  extent,"  and  different  kinds  of  secretion  from  the 
mucous  membrane  of  this  organ  are  mentioned  as  occurring  in  different 
diseases,  and  it  should  have  been  added  in  the  same  disease  in  different 
temperaments. 

After  describing  the  various  kinds  of  coating  on  the  tongue,  together 
with  their  respective  indications,  which  it  is  not  necessary  here  to 
enumerate,  the  occurrence  of  false  membranes. and  pustules,  resulting 
from  peculiar  forms  of  mucous  secretion,  are  next  mentioned.  The 
former  show  themselves  either  as  small  white  points,  or  large  patches 
and  sometimes  they  are*  said  to  envelop  the  "whole  tongue.  The  color 
is  "  sometimes  white,  sometimes  yellow,  and  sometimes  red,''  and  the 
greater  the  surface  covered  by  them,  the  more  unfavorable  is  the  prog- 
nosis regarded.  "Pustules  on  the  tongue,"  says  our  author,  "are 
sometimes  idiopathic,  but  in  most  cases  symptomatic.  They  are  either 
distinct  or  confluent ;  the  confluent  are  the  worst.  Those  which  are 
hardish  and  dry,  and  also  those  "which  are  blue,  and  those  of  a  black- 
ish appearance,  which  sometimes  occur  in  acute  diseases,  are  of  an  un- 
favorable import."  On  the  other  hand,  those  which  have  a  whitish, 
soft,  moist,  and  semi-transparent  appearance,  are  less  unfavorable,  and 
when  the  aphthce,  or  eruption,  are  repeated,  it  portends  a  longer  con- 
tinuance of  the  malady.  The  pustules  or  aphthce  are  mentioned  as 
being  frequent  accompaniments  to  the  following  diseases,  namely,  gas- 
tritis, catarrhs,  enteritis,  metritis,  dysentery,  cholera  infantum,  periton- 
itis, intermittent  and  typhus  fevers,  pleuritis,  pneumonia,  and  the  third 
stage  of  pulmonary  consumption.  Their  prognosis  is  said  to  be  favor- 
able w^hen  they  "  appear  with  critical  discharges  after  the  seventh  day," 
and  unfavorable  "when  they  occur  as  a  consequence  of  a  general  sinking 
of  the  physical  powers  of  the  body. 

But  it  is  unnecessary  to  enumerate  all  of  the  pathognomonic  indi- 
cations of  the  various  morbid  phenomena  described  by  semeiologists ; 
we  have  noticed  more  of  them  than  was  our  intention  to  have  done. 
We  shall,  therefore,  conclude  the  present  inquiry,  by  simply  observing 
that  the  indications  furnished  by  the  physical  characteristics,  not  only 
of  the  tongue,  but  by  those  also  of  the  teeth,  the  gums,  salivary  cal- 
culus, the  lips,  and  fluids  of  the  mouth,  are,  as  we  have  endeavored  to 
show,  essential  to  the  successful  exercise  of  the  duties  both  of  the 
dental  and  medical  practitioner. 


262  DENTAL  PATHOLOGY,  THERAPEUTICS. 


CHAPTER  X. 

DISEASES   OF   THE   DENTAL   PULP. 

rpHE  pulp  of  a  tooth,  from  the  high  degree  of  vitality  with  which 
-L  it  is  endowed,  is  one  of  the  most  sensitive  structures  of  the  body, 
and,  like  other  parts,  is  liable  to  become  the  seat  of  various  morbid 
phenomena.  Its  susceptibility  to  morbid  impressions  is  influenced  by 
a  variety  of  circumstances,  such  as  temperament,  habit  of  body,  the 
state  of  the  constitutional  health,  the  condition  of  the  hard  structures 
of  the  tooth,  etc.  A  cause,  which  under  some  circumstances  would 
not  be  productive  of  the  slightest  disturbance,  might,  under  others, 
give  rise  to  active  inflammation,  with  all  its  painful  and  disagreeable 
concomitants.  Increased  irritability  (hypersesthesia)  may  exist  inde- 
pendently of  any  organic  change,  either  in  the  pulp,  dentine,  or 
enamel.  Examples  are  often  met  with  in  females  during  gestation ; 
but  it  arises  more  frequently  as  a  consequence  of  caries  than  from  any 
other  cause  connected  with  the  teeth.  Even  before  the  disease  has 
penetrated  to  the  central  chamber  of  the  organ,  the  pulp  often  assumes 
a  most  wonderful  and  marked  increase  of  irritability,  either  from 
functional  disturbance  arising  froija  decomposition  of  the  dentine,  im- 
paired relationship  between  the  two,  or  from  being  more  exposed  to 
the  action  of  external  deleterious  agents.  Impaired  digestion,  as  well 
as  a  disordered  state  of  other  functions  of  the  body,  frequently  pro- 
duces the  same  effect. 

The  susceptibility  of  the  pulp  to  impressions  of  heat  and  cold,  and 
of  acids,  is  always  increased  by  heightened  irritability.  When  this 
exists  to  any  considerable  degree,  the  mere  contact  of  these  agents 
with  the  tooth  is  often  productive  of  severe  pain,  which,  on  their  re- 
moval, usually  very  soon  subsides.  The  pulp,  however,  may  remain 
in  this  condition  for  months,  and  even  years,  without  becoming  the 
seat  of  inflammatory  action. 

Preternatural  sensibility  of  the  dentine,  whether  in  a  sound  or  par- 
tially decomposed  state,  augments  very  appreciably  the  irritability 
of  the  pulp.  The  sensibility  of  dentine  is  sometimes  so  much  increased 
that  the  mere  contact  of  any  hard  substance  with  a  part  which  has 
become  exposed  by  the  destruction  of  a  portion  of  the  enamel,  is  often 
productive  of  severe  pain.  Impressions  of  heat  and  cold  conveyed 
through  the  conducting  medium  of  a  metallic  filling,  or  through  a  thin 
covering  of  dentine,  as  sometimes  happens  when  a  considerable  portion 


IRRITATION   OF   THE   PULP.  263 

of  the  tooth  has  been  worn  away,  is  a  very  frequent  cause  of  height- 
ened irritability  of  the  pulp.  With  its  susceptibility  thus  increased, 
the  impressions  produced  by  these  agents  are  often  a  source  of  irrita- 
tion, and  even  of  inflammation  and  suppuration,  causing  the  death  of 
the  entire  crown  and  inner  walls  of  the  root  of  the  tooth.  At  other 
times,  the  irritation  is  only  followed  by  slight  increase  of  vascular 
action  and  an  effusion  of  plastic  lymph  over  the  affected  part  of  the 
pulp,  which  is  gradually  converted  into  osteo-dentine ;  and  thus  a 
barrier  is  interposed  between  it  and  the  irritating  agents. 

IRRITATION. 

The  pulp  of  a  tooth  may  become  the  seat  of  severe  pain  even  when 
there  is  no  inflammation.  The  slightest  increase  of  vascular  action, 
when  this  organ  is  in  a  preternaturally  irritable  condition,  is  pi'O- 
ductive  of  more  or  less  irritation.  The  pressure  of  the  slightly  dis- 
tended vessels  upon  the  nervous  filaments  distributed  upon  it,  at  such 
times,  is  sufficient  to  cause  great  pain. 

Impressions  of  heat  and  cold  are  conveyed  more  readily  to  the  pulp 
when  the  dentine  is  in  a  morbidly  sensitive  condition,  and  when  this 
is  the  case,  they  produce  a  more  powerful  effect. 

The  remedial  indications  of  pain  in  a  tooth  arising  simply  from 
irritation  of  the  pulp,  consist  in  the  removal  of  the  primary  and  ex- 
citing causes.  When  produced  by  impressions  of  heat  and  cold  con- 
veyed to  it  through  the  conducting  medium  of  a  metallic  filling  and 
intervening  super-sensitive  dentine,  if  the  severity  and  continuance  of 
pain  is  such  as  to  warrant  the  belief  that  it  will  give  rise  to  inflamma- 
tion, the  filling  should  be  removed  and  some  non-conducting  substance 
placed  in  the  bottom  of  the  cavity  before  replacing  it.  If  this  is  done 
before  inflammation  actually  takes  place,  it  will  prevent  subsequent 
irritation  from  these  causes.  It  is  worthy  of  remark,  however,  that 
the  pain  thus  produced  is  in  proportion  to  the  sensibility  of  the  sub- 
jacent dentine.  If  this  is  destroyed  previously  to  filling  the  tooth, 
irritation  of  the  pulp  will  be  as  effectually  prevented  as  by  the 
interposition  of  a  non-conducting  substance.  But  in  the  application 
of  agents  for  this  purpose,  there  is  danger  of  destroying  the  vitality 
of  the  pulp.  The  employment  of  them,  however,  is  resorted  to  more 
frequently  to  prevent  pain  during  the  removal  of  caries  than  to  relieve 
any  subsequent  irritation  from  impressions  of  heat  and  cold.  (See 
Sensitiveness  of  Dentine.) 

Although  a  frequent  cause,  yet  a  metallic  filling  is  not  the  only 
medium  through  which  impressions  of  heat  and  cold  are  conveyed  to 
the  dental  pulp.  When  the  dentine  on  the  coronal  extremity  or  side 
of  a  tooth  becomes  very  thin  from  loss  of  substance,  occasioned  by  me- 


264  DENTAL,  PATHOLOGY,  THERAPEUTICS. 

chanical  or  chemical  abrasion,  by  the  use  of  the  file,  erosion,  or  other 
cause,  the  pulp  sometimes  becomes  painfully  susceptible  to  the  action 
of  these  agents.  Loss  of  substance  from  any  of  these  causes  is  also 
often  attended  by  exalted  sensibility  of  the  exposed  dentine ;  and  when 
this  is  the  case,  the  contact  of  acids  with  it  is  productive  of  more  or 
less  pain.  Nature,  however,  usually  prevents  the  painful  consequences 
that  would  naturally  arise  from  continued  abrasion  of  the  coronal  ends 
of  the  teeth,  and  the  consequent  exposure  of  their  nervous  pulp,  by  the 
gradual  ossification  of  this  organ ;  so  that  by  the  time  it  would  become 
exposed,  it  is  converted  into  osteo-dentine.  But  this  does  not  always 
take  place  in  time  to  prevent  irritation  and  pain. 

When  irritation  of  the  pulp  occurs  in  a  tooth  that  has  been  cut  away 
on  one  or  both  sides,  so  much  so  as  to  leave  only  a  thin  covering  of 
.dentine,  the  best  known  means  of  preventing  morbid  sensibility  is  to 
keep  the  filed  surface  constantly  clean  by  frequent  friction  with  a 
brush  and  waxed  floss  silk,  or  with  some  other  suitable  substance. 
This  operation  should  be  repeated  after  each  meal,  and  in  the  morning 
immediately  after  rising,  and  at  night  before  going  to  bed.  The  ap- 
plication of  nitrate  of  silver,  for  sensitiveness  arising  from  loss  of  sub- 
stance or  from  exalted  sensibility  of  exposed  dentine,  has  proved 
successful.  The  nitrate  in  the  solid  form  may  be  applied  by  enveloping 
a  portion  of  the  stick  with  wax,  which  will  enable  the  operator  to  handle 
it  with  impunity.  Or  the  end  of  a  silver  wire  may  be  dipped  in  nitric 
acid  and  the  application  be  thus  made  to  the  sensitive  surface,  taking 
care  to  protect  the  adjacent  parts.  Some  are  in  the  habit  of  applying 
salt,  as  soon  as  the  sensitive  surface  has  been  touched  with  the  nitrate, 
to  neutralize  its  elFects.  To  prevent  contact  with  the  gum,  when  it  is 
necessary  to  apply  the  nitrate  to  the  necks  of  the  teeth,  a  coating  of 
collodion  may  be  painted  on  them  with  a  camel's-hair  brush.  Chromic 
acid  has  also  been  used  in  these  cases  with  success. 

When  caries  has  extended  to  the  central  cavity,  irritation  is  often 
produced  by  contact  of  partially  decomposed  portions  of  dentine  or 
other  foreign  matter  with  the  pulp.  The  proper  remedial  indication 
in  such  cases,  it  is  scarcely  necessary  to  say,  consists  in  the  removal 
of  all  matter  from  the  teeth  that  can  either  act  as  a  mechanical  or 
chemical  irritant.  This  done,  the  cavity  in  the  tooth,  supposing  the 
pulp  to  be  in  a  healthy  condition,  should  be  properly  filled. 

But  when  the  irritation  arises  as  a  consequence  of  exalted  irritability 
and  increased  vascular  action  of  the  pulp,  dependent  upon  disease  or 
altered  function  of  some  other  part  or  parts  of  the  body,  the  remedial 
indications  are  different.  The  treatment  then  should  be  addressed  to 
the  primary  affection.  Examples  of  this  sort  are  of  frequent  occurrence. 
They  are  met  with  almost  daily,  particularly  in  females  during  gesta- 


INFLAMMATION — PULPITIS.  265 

tion,  in  dyspeptic  individuals,  and  in  persons  affected  with  gout  and 
chronic  rheumatism.  They  are  also  sometimes  met  with  in  individuals 
who  have  been  exposed  to  miasmatic  emanations  of  marshy  districts, 
when  the  irritation  assumes  an  intermittent  form,  occurring  at  stated 
intervals  of  twenty-four,  forty-eight,  or  seventy-two  hours,  and  con- 
tinuing from  one  to  three  hours.  Some  of  the  worst  forms  of  toothache 
are  produced  by  one  or  other  of  these  causes. 

The  local  disturbance,  when  it  occurs  in  females  during  pregnancy, 
may  generally  be  removed  by  mild  aperients,  warm  foot-bath,  and  ano- 
dynes at  night  on  going  to  bed.  When  it  depends  upon  other  kinds 
of  derangement  of  the  uterine  organs,  treatment  suited  to  the  peculiar 
indications  of  the  case  should  be  instituted.  When  it  occurs  in  a 
person  affected  with  dyspepsia,  rheumatism,  or  gout,  the  constitutional 
treatment  required  by  the  particular  disease  constitutes  the  proper 
remedy.  When  the  irritation  assumes  an  intermittent  form,  an  emetic 
or  cathartic,  followed  by  quinine,  will  generally  put  a  stop  to  the  local 
disturbance,  provided  it  has  no  connection  with  caries  of  the  crown  of 
the  tooth. 

INFLAMMATIOISr — PULPITIS. 

The  pulp  of  a  tooth,  when  healthy,  has  a  grayish-white  appearance, 
and  its  capillaries  are  invisible  to  the  naked  eye,  but  when  it  becomes 
the  seat  of  acute  or  acti've  inflammation,  they  may  be  distinctly  seen,  as 
the  organ  then  assumes  a  bright  red  color.  Inflammation,  having  estab- 
lished itself,  soon  extends  to  every  part  of  the  pulp,  and  even  to  the 
alveolo-dental  periosteum.  When  permitted  to  run  its  course  un- 
interruptedly, it  usually  terminates  in  suppuration  in  from  three  to 
eight  or  ten  days. 

The  unyielding  nature  of  the  walls  of  the  cavity  in  which  it  is  on 
all  sides  inclosed  renders  expansion  of  the  pulp  impossible,  and  as  its 
capillaries  become  distended  with  blood,  they  press  on  the  nervous 
filaments  which  are  everywhere  distributed  upon  it,  causing  at  first 
constant  gnawing  pain ;  which  afterward,  as  the  distention  of  the 
vessels  increases,  becomes  severe,  deep-seated,  throbbing,  and  sometimes 
almost  insupportable. 

Inflammation  may  attack  the  pulps  of  sound  teeth  as  well  as  those 
affected  with  caries ;  but  it  occurs  more  frequently  in  the  latter  than 
in  the  former,  and  it  is  oftener  met  with  before  than  after  the  pulp  has 
become  actually  exposed.  The  severity  of  the  pain,  however,  is  de- 
termined by  the  condition  of  the  tooth,  the  state  of  the  general  health, 
and  the  causes  concerned  in  its  production.  The  pulp,  when  in  an 
irritable  condition,  is  more  liable  to  become  the  seat  of  acute  inflam- 
mation than  when  in  a  perfectly  healthy  state,  and  the  occurrence  of 
suppuration  is  soon  followed  by  alveolar  abscess,  unless  an  opening  is 


266  DENTAL  PATHOLOGY,  THERAPEUTICS. 

made  immediately  through  the  crown,  neck,  or  root  of  the  tooth,  for 
the  escape  of  the  matter. 

The  effusion  of  lymph,  which  takes  place  during  the  inflammatory 
stage,  and  which,  under  other  circumstances,  and  when  the  inflamma- 
tion is  less  severe,  is  made  to  play  an  important  part  in  the  reparation 
of  the  injury,  compresses  the  pulp  into  still  narrower  limits  as  it 
accumulates  in  quantity,  and  thus  becomes  an  additional  source  of 
irrritation,  adding  fuel  to  the  flame  already  lighted  up. 

Inflammation  of  the  pulp  may  be  caused  by  a  blow  on  the  tooth  ;  by 
impressions  of  heat  and  cold  conveyed  to  it  through  the  enamel  and 
dentine,  or  through  a  metallic  filling ;  or  by  the  pressure  of  a  filling, 
or  the  direct  contact  of  external  irritating  agents,  such  as  disorganized 
portions  of  the  tooth,  particles  of  alimentary  substances,  acrid  humors, 
etc.  But,  as  we  have  stated  in  another  place,  inflammation  of  the 
dental  pulp  is  not  always  a  necessary  consequence  of  impressions  of 
heat  and  cold;  pain  may  be  produced  by  them  when  it  does  not  exist ; 
but  in  this  case  it  usually  subsides  soon  after  the  removal  of  the  irri- 
tant. The  pulp  of  a  tooth  may  be  exposed  for  months,  and  subjected 
several  times  a  day  to  the  actual  contact  of  foreign  bodies,  without 
becoming  the  seat  of  acute  inflammation.  The  irritation  and  increased 
vascular  action  thus  occasioned  are,  no  doubt,  removed  by  the  effiision 
of  lymph  to  which  they  give  rise,  and  the  pulp,  after  it  has  become 
exposed,  having  room  to  expand  as  its  vessels  become  distended,  does 
not  suffer  irritation  from  the  pressure  to  which  it  would  otherwise  be 
subjected. 

When  suppuration  takes  place,  the  pain  very  nearly  ceases,  but  the 
tooth  for  a  time  remains  sore  to  the  touch,  and  its  appearance  is 
changed.  It  has  no  longer  the  peculiar  animated  translucency  of  a 
living  tooth,  but  has  assumed  an  opaque,  muddy,  or  brownish  aspect. 
With  the  disorganization  of  the  pulp,  tKe  entire  crown  and  inner 
walls  of  the  root  lose  their  vitality ;  still,  if  the  alveolo-dental  peri- 
osteum has  not  become  seriously  involved  in  disease,  the  vascular 
and  nervous  supply  furnished  to  the  cementum  is  often  sufficient  to 
prevent  the  tooth  from  exerting  any  injurious  influence  upon  the 
surrounding  and  more  highly  vitalized  parts.  The  cementum,  being 
more  analogous  in  structure  to  true  osseous  tissue  than  dentine,  now 
plays  an  important  part  in  the  animal  economy.  It  being  more 
liberally  supplied  with  vitality  and  with  nutritive  juices,  and  not 
being  sensibly  affected  by  the  death  of  the  other  parts  of  the  organ,  it 
keeps  up  the  living  relationship  of  the  tooth  with  the  alveolo-dental 
periosteum,  at  least  sufficiently  to  prevent  it  from  acting  perceptibly 
as  a  morbid  irritant. 

Inflammation  of  the  pulp  of  a  tooth,  besides  the  local  pain  with 


INFLAMMATION — PULPITIS.  267 

which  it  is  attended,  often  gives  rise  to  a  ti'ain  of  constitutional  morbid 
phenomena,  usually  of  a  mild,  but  sometimes  of  an  aggravated  and 
even  threatening  character.  Among  these  are  headache,  constipation 
of  the  boivels,  furred  tongue,  dryness  of  the  skin,  quick,  full,  and  hard 
pulse,  earache,  ophthalmia,  disease  of  the  maxillary  sinus,  etc. 

The  amount  of  constitutional  disturbance  arising  from  inflammation 
of  the  pulp  of  a  tooth  depends  on  the  state  of  the  general  health, 
and  the  nervous  irritability  of  the  system  at  the  time.  In  the 
majority  of  cases  it  occasions  but  little  inconvenience,  and  disappears 
as  soon  as  the  inflammation  ceases,  but  sometimes  it  assumes  a  very 
alarming  character.  A  fatal  case  of  tetanus,  produced  by  inflamma- 
tion of  the  pulp  of  a  lower  molar,  occurred  a  number  of  years  ago  in 
Baltimore.  The  subject  was  a  young  lady  about  eighteen  years  of  age. 
The  system  at  the  time,  from  great  bodily  fatigue  and  mental  excite- 
ment, was  in  an  exceedingly  irritable  condition,  but  in  other  respects, 
though  constitutionally  rather  delicate,  she  was  in  the  enjoyment  of 
good  health. 

There  is  not  an  organ  or  tissue  of  the  body  in  which  acute  inflam- 
mation is  more  intractable  in  its  nature  and  rapid  in  its  progress, 
than  in  the  pulp  of  a  tooth  ;  and  when  we  take  into  consideration  its 
situation,  and  its  physical  and  vital  peculiarities,  it  is  not  to  be  won- 
dered that  it  should,  in  so  large  a  majority  of  the  cases,  terminate  in 
the  disorganization  of  the  part.  Still,  it  may  sometimes  be  arrested, 
and  the  remedial  indications  here,  though  they  cannot  be  as  readily 
and  fully  carried  out,  are  the  same  as  for  inflammation  in  any  other 
part  of  the  body.  The  first  and  most  important  one  consists  in  the 
removal  of  all  local  and  exciting  causes.  For  simple  exposure  of 
the  pulp,  without  sloughing,  the  first  step,  after  the  removal  of  all 
irritants  from  the  carious  cavity,  is  to  attempt  the  reduction  of 
inflammation  and  the  prevention  of  the  efiusion  of  serum  or  lymph, 
by  cleansing  the  exposed  surface  with  tepid  water,  and,  after  careful 
drying,  to  bathe  it  with  dilute  tincture  of  aconite,  when  it  may  be 
covered  with  a  thin  coating  of  a  solution  of  gutta  percha  in  chloroform, 
or  glycerine,  or  collodion  carefully  applied,  and  the  tooth  protected 
from  irritation.  Some  prefer  the  use  of  a  preparation  composed  of 
crystallized  carbolic  acid  rendered  fluid  by  a  small  quantity  of  chloro- 
form. This  preparatory  treatment,  if  successful,  is  to  be  followed  by 
the  process  of  "  capping  the  pulp,"  as  described  in  another  place. 
If  it  be  the  result  of  irritation  produced  by  the  pressure  of  a  filling, 
the  plug  should  be  immediately  removed,  leeches  applied  to  the  gum 
of  the  affected  tooth,  and,  if  the  patient  be  of  a  full  habit,  blood  may 
be  taken  from  the  arm,  and  a  brisk  saline  purgative  prescribed.  The 
removal  of  the  filling,  however,  when  the  inflammation  has  previously 


268  DENTAL  PATHOLOGY,  THERAPEUTICS. 

made  much  progress,  will  not  prevent  suppuration,  but  it  may  keep  it 
from  extending  to  every  part  of  the  pulp.  When  an  external  opening 
is  made  for  the  escape  of  the  matter,  the  moment  suppuration  takes 
place  the  remaining  portion  of  the  pulp  will  be  relieved  from  the 
pressure  which  caused  the  irritation,  and  then  the  inflammatory  action 
may  cease.  But  if  the  matter  remains  in  the  central  cavity  of  the  tooth, 
the  part  of  the  pulp  which  has  not  suppurated  will  still  be  subjected 
to  pressure,  and  the  inflammation  and  suppuration  will  go  on  until  the 
entire  organ  perishes.  Nor  will  the  disorganizing  process  stop  here. 
The  alveolo-dental  membrane  at  the  extremity  of  the  root  will  soon 
become  implicated,  and  in  a  short  time  alveolar  abscess  will  form, 
thus  terminating  the  acute  stage  of  the  disease. 

There  may  be  no  indications  of  irritation  or  inflammation  for 
•  several  weeks,  or  even  months,  after  a  tooth  has  been  filled ;  but 
at  the  expiration  of  this  time,  the  pulp,  from  increased  irritability, 
caused  perhaps  by  some  change  in  the  state  of  the  patient's  general 
health,  may  be  attacked  by  inflammation.  Although  this  very  seldom 
happens,  it  does,  nevertheless,  sometimes  occur.  When  there  is  reason 
to  apprehend  that  it  is  about  to  take  place — and  it  may  be  suspected 
if  pain  is  felt  in  the  tooth  when  anything  hot  or  cold  is  taken  into  the 
mouth,  or  if  it  becomes  the  seat  of  gnawing  or  gradually  increasing 
pain — the  filling  should  be  removed.  If  the  pain  now  ceases,  a  thick 
layer  of  gutta  percha  dissolved  in  chloroform,  or  Hill's  stopping,  or 
os-artificiel,  or  oxy-phosphate  of  zinc  preparation,  may  be  placed  in 
the  bottom  of  the  cavity,  and  the  filling  replaced ;  using  the  pre- 
caution, as  before  directed,  to  introduce  the  gold  in  such  a  w^ay  as 
to  prevent  the  liability  of  depressing  the  floor  of  the  cavity ;  or  a 
temporary  filling  of  some  plastic  non-irritating  substance,  such  as  Hill's 
stopping  or  the  oxyphosphate  of  zinc,  may  be  inserted  and  permitted  to 
remain  for  some  time,  when  a  more  durable  filling  may  be  introduced. 
But  if  the  pain  and  inflammation  continue  unabated,  and  the  applica- 
tion of  such  escharotics  as  carbolic  acid,  chloride  of  zinc,  nitrate  of 
silver,  and  chromic  acid,  fails  to  reduce  the  congestion  and  hyper- 
trophy, it  may  be  necessary  to  extract  the  tooth,  or  expose  the  pulp, 
and  destroy  its  vitality  by  applying  to  it  some  powerful  escharotic. 
When  this  is  done,  it  is  usually  wath  the  view  of  securing  the  retention 
and  preservation  of  the  tooth  by  filling  the  pulp-cavity  and  root,  an 
operation  now  very  frequently  performed  by  dentists. 

The  abstraction  of  blood  directly  from  the  pulp,  one  might  suppose, 
would  often  be  successful  in  arresting  the  inflammation  ;  but  we  do 
not  think  this  has  been  resorted  to  for  this  purpose  sufiiciently  often  to 
determine  its  therapeutic  value.  At  any  rate,  it  seems  reasonable  to 
suppose  that  if,  by  this  means,  the  congestion  of  the  capillaries  could 


INFLAMMATION PULPITIS.  269 

be  removed,  the  tumefied  pulp  would  be  reduced  ^o  its  natural  size, 
and  be  relieved  from  the  pressure  to  which,  as  a  consequence  of  its 
distended  condition,  it  is  subjected.  To  obtain  the  largest  amount  of 
benefit  capable  of  being  derived  from  the  operation,  the  opening  should 
be  made  in  that  portion  where  one  of  the  principal  arteries  would  be 
most  likely  to  be  punctured;  and  this,  it  seems  to  us,  would  be  just 
whei'e  the  canal  of  the  root  entei'S  the  chamber  of  the  crown  of  the 
tooth.  But  in  making  the  puncture  here,  the  pulp  being  very  small 
at  this  point,  there  is  danger  of  cutting  it  ofl^;  and  as  reunion  might 
not  take  place,  the  portion  in  the  central  cavity  would  necessarily 
perish. 

If  the  pulp  were  exposed,  there  would  be  a  better  opportunity  of 
relieving  the  congested  condition  of  its  capillaries  by  the  abstraction 
of  blood ;  but  the  difficulty  of  obtaining  free  access  to  the  organ  by 
drilling  a  hole  through  the  intervening  dentine  is  very  great ;  the 
tooth,  w^hen  sufifering  from  inflammation,  being  usually  so  sore  to  the 
touch  that  the  slightest  pressure  is  productive  of  great  pain.  Deple- 
tion of  the  pulp  maybe  accomplished  by  means  of  a  fine,  sharp-pointed 
instrument ;  or  Dr.  Allport's  method  of  treating  exposed  pulps  may 
be  resorted  to,  namely,  that  of  excising  a  portion  of  the  pulp  at  the 
orifice  of  exposure,  and  then  drawing  the  edges  together  so  as  to  induce 
union  by  first  intention.  If  the  tooth  is  an  incisor  or  cuspid,  and  the 
pulp  cannot  be  restored  to  health,  its  vitality  should  be  destroyed  ;  or, 
if  suppuration  has  previously  taken  place,  an  opening  should  be  made 
into  the  chamber  of  the  tooth  as  before  directed,  for  the  escape  of  the 
matter.  Should  it  be  found,  after  this  has  escaped,  that  disorganiza- 
tion has  not  extended  to  every  part  of  the  pulp,  the  remaining  portion 
may  be  destroyed  in  the  manner  hereafter  to  be  described.  This  done, 
the  pulp  cavity  and  root  may  be  filled,  as  soon  as  the  inflammation  of 
the  socket  has  completely  subsided. 

Chronic  inflammation  of  the  dental  pulp  often  occurs  where  the 
chamber  of  a  tooth  has  become  gradually  exposed  by  caries  of  the 
dentine;  and  when  this  happens,  the  action  of  the  fluids  of  the  mouth, 
and  of  other  foreign  substances  which  obtain  access  to  the  cavity,  as 
well  as  of  the  decomposed  portions  of  the  tooth  substance,  causes  an 
increase  of  vascular  action  in  the  exposed  part,  followed  very  often  by 
a  slight  discharge  ;  but  the  morbid  action  thus  induced  is  comparatively 
seldom  accompanied  by  pain.  The  pulp  may  remain  thus  partially 
exposed  for  months,  and  even  years,  without  causing  any  other  incon- 
venience than  a  momentary  twinge  of  pain  when  some  hard  substance 
is  accidentally  introduced  into  the  cavity  of  the  tooth,  which  subsides 
immediately  after  its  removal.  Sooner  or  later,  however,  the  pain  thus 
excited  will  become  more  permanent,  continuing,  each  time  it  occurs, 


270  DENTAL,   PATHOLOGY,  THERAPEUTICS. 

from  five  to  ten  minutes  to  one  or  more  hours  after  the  cause  of  the 
irritation  has  been  removed.  If  a  tooth  be  filled  under  such  circum- 
stances, the  pressure  of  the  fluid  upon  the  pulp,  which  is  poured  out 
from  its  exposed  surface  beneath  the  filling,  will  give  rise  to  a  more 
general  and  active  form  of  inflammatory  action.  Pain  is  often  expe- 
rienced before  actual  exposure  of  the  pulp  occurs. 

The  liability  of  the  tooth  to  ache  increases  as  the  pulp  becomes 
more  and  more  exposed  by  the  gradual  decomposition  of  the  dentine ; 
and  the  inflammation  may  ultimately  assume  a  more  active  form,  when 
the  pain  becomes  very  acute,  owing  to  the  consequent  effusion  into  tissue 
surrounded  by  unyielding  walls,  or  the  pulp  may  become  the  seat  of 
fungous  growth  or  it  may  be  absorbed  or  destroyed  by  ulceration,  or 
by  gangrene  and  mortification.  Cases  sometimes  occur  in  which  the 
•  disease  is  attended  with  severe  darting  pains,  often  occurring  several 
times  in  the  space  of  two  or  three  minutes,  succeeded  by  intervals  of 
perfect  ease  for  many  hours.  At  other  times  it  is  attended  by  dull, 
aching  pains,  aggravated  by  taking  sweet  or  acid  substances  into  the 
mouth.  In  cases  of  this  sort,  the  application  of  heating  or  stimulating 
substances  to  the  exposed  surface  of  the  pulp  will  usually  procure  re- 
lief. Permanent  exemption  from  pain,  however,  is  not  always  obtained, 
and,  sooner  or  later,  it  may  become  necessary  either  to  destroy  the  pulp 
or  to  extract  the  tooth.  In  some  cases,  however,  where  the  pulp 
becomes  exposed  by  the  action  of  caries,  no  pain  is  experienced  except 
by  contact  of  foreign  substances  with  the  exposed  surface. 

The  body  of  the  pulp,  when  the  organ  becomes  exposed  from  a  de- 
cayed opening  in  the  grinding  surface  of  a  molar,  is  sometimes  absorbed, 
while  its  prolongations  in  the  roots  often  remain  unchanged  for  two  or 
more  years. 

Exposure  of  the  pulp  is  usually  attended  with  ulceration — a  disor- 
ganizing process,  which  often  causes  the  destruction  of  a  large  portion 
of  the  part  occupying  the  central  chamber  of  the  crown  of  the  tooth, 
making  in  it  numerous  little  excavations.  The  ulcerated  surface  usu- 
ally presents  a  yellowish  appearance,  that  of  an  irritable  ulcer,  with 
the  exudation  of  a  serous  or  sanguiuo-serous  fluid,  a  condition  however, 
which  must  not  be  confounded  with  a  state  of  suppuration.  The  ex- 
uded fluid  is  very  oflTensive,  as  it  rapidly  decomposes,  and  its  reaction 
is  alkaline ;  when  the  disorganizing  process  is  arrested  before  it  has 
effected  the  destruction  of  any  very  large  portion  of  the  pulp,  it  usually 
becomes  covered  with  healthy  granulations. 

When  the  inflammation  occurs  in  cachectic  individuals  it  often  as- 
sumes an  acute  form,  and  sometimes  terminates  in  gangrene  and  mor- 
tification. The  loss  of  vitality  may  be  confined  to  the  body  of  the 
pulp,  or  it  may  extend  to  every  part  of  the  organ.     In  the  former 


INFLAMMATION — PULPITIS.  271 

case  the  pain  continues,  but  in  the  latter  it  ceases  as  soon  as  mortifica- 
tion takes  place.  When  this  happens,  the  entire  pulp,  which  has  now 
a  dark-brown  or  black  color,  may  be  removed.  But  this  is  not  a  very 
common  termination. 

The  symptoms  of  chronic  as  well  as  acute  inflammation  are  always 
modified  by  the  state  of  the  general  health,  habit  of  body,  and  the 
temperament  of  the  individual.  The  pain  attending  the  former,  how- 
ever, is  periodical,  occurring  at  irregular  and  uncertain  intervals,  and 
constitutes  that  variety  of  toothache  so  often  relieved  by  local  applica- 
tions ;  whereas,  in  the  latter,  it  is  constant. 

In  chronic  inflammation,  which  implies  a  state  of  ulceration,  the 
pulp  is  either  actually  exposed  or  only  covered  by  decomposed  or 
partially  decomposed  dentine,  and  the  diseased  surface  rarely  embraces 
a  larger  circumference  than  that  described  by  the  bottom  of  the  decayed 
cavity.  The  inflammation,  therefore,  is  local  as  well  as  chronic,  but 
nevertheless,  it  is  often  of  so  persistent  a  character,  as  to  render  its  re- 
moval exceedingly  difiicult.  The  dentist,  however,  is  not  so  much 
restricted  in  the  application  of  remedies  as  in  the  treatment  of  acute 
inflammation,  and  to  the  action  of  which  it  yields  more  readily.  But 
notwithstanding  all  this,  he  will  necessarily  encounter  difiiculties  in  his 
efforts  to  subdue  it.  A  greater  length  of  time  is  sometimes  required 
than  the  patient  is  willing  to  give ;  and  the  opening  through  the  crown 
to  the  central  cavity  is  frequently  too  small,  previously  to  the  removal 
of  the  partially  decomposed  dentine,  to  admit  of  the  direct  application 
of  the  necessary  remedial  agent  to  the  inflamed  surface  of  the  pulp. 
Again,  it  often  happens,  that  the  situation  of  the  tooth  and  cavity  are 
such  as  to  prevent  a  complete  view  of  the  diseased  part.  It  is  im- 
portant that  the  operator  should  get  such  a  view  to  enable  him  to 
determine  whether  the  inflamed  surface  is  ulcerated,  or  pours  out  a 
serous  fluid ;  or  whether  the  morbid  condition  is  simply  one  of  irri- 
tation, produced  by  the  presence  of  acrid  matter,  or  of  partially  or 
wholly  decomposed  dentine.  Unless  his  diagnosis  is  correct,  his  pre- 
scription will  be  as  likely  to  do  harm  as  good ;  but,  having  ascertained 
the  exact  character  of  the  disease,  he  may  often  be  able  to  institute 
treatment  that  will  result  in  the  restoration  of  the  pulp  and  the  pre- 
servation of  the  tooth. 

It  is  important,  too,  to  understand  the  part  which  nature  plays  in 
the  curative  process ;  for  cure  here,  as  in  other  parts  of  the  body,  is 
effected  by  that  internal  force  which,  as  Chomel  says,  "  presides  over 
all  the  phenomena  of  life,  contends  unremittingly  with  physical  and 
chemical  laws,  receives  the  impressions  of  deleterious  agents,  reacts 
against  them,  and  efiects  the  resolution  of  disease."  This  vital  force  is 
sometimes  exercised  in  the  cure  of  disease  in  the  pulp  of  a  tooth,  but 


272  DENTAL  PATHOLOGY,  THERAPEUTICS.   . 

more  frequently  in  its  prevention ;  as  is  shown  by  the  gradual  ossifica- 
tion of  the  organ  in  those  cases  where  it  would  otherwise  become  ex- 
posed by  mechanical  or  spontaneous  abrasion  of  the  solid  structures 
which  inclose  it ;  and  occasionally  by  the  formation  of  secondary  den- 
tine upon  the  surface  of  the  original  or  primary  dentine  at  a  point 
toward  which  the  caries  is  advancing.  Nature,  no  doubt,  would  always 
provide  in  this  way  against  the  exposure  of  the  pulp,  if  the  occurrence 
were  always  long  enough  preceded  by  sufficient  irritation  or  increase 
of  vascular  action  in  it  to  call  her  energies  into  operation.  But  the 
formation  of  osteo-dentine,  which  constitutes  the  protective  wall  of  de- 
fence, is  a  tardy  process,  and,  as  a  general  rule,  proceeds  more  slowly 
than  the  caries  in  the  tooth,  which  causes  the  exposure  of  the  pulp. 
Besides,  it  often  happens  that  its  approach  is  not  announced  by  the 
slightest  irritation,  a  condition  necessary  to  the  new  formation,  until  it 
reaches  the  central  cavity.  At  other  times,  the  approach  of  the  disease 
gives  rise  to  too  much  irritation,  a  condition  equally  unfavorable  to  the 
dentinification  of  the  pulp.  Thus,  no  protective  covering  being  formed, 
it  soon  becomes  exposed,  when  it  is  subjected  to  the  action  of  such 
irritating  agents  as  may  chance  to  be  brought  into  contact  with  it. 
Hence,  its  liability  to  become  the  seat  of  chronic  inflammation  as  well 
as  other  forms  of  diseased  action. 

If  the  disease  is  attended  with  pain,  the  removal  of  this  must  first 
claim  attention,  and  should  be  effected  with  as  little  delay  as  possible ; 
otherwise  the  morbid  action  may  extend  to  every  part  of  the  pulp  and 
peridental  membrane,  and  assume  a  more  active  and  unmanageable 
form.  If  the  pain  is  the  result  of  irritation  produced  by  the  direct 
action  of  mechanical  or  chemical  agents,  the  cavity  in  the  tooth  should 
at  once  be  carefully  freed  from  all  extraneous  substances  and  decom- 
posed portions  of  dentine.  This  done,  a  dossil  of  raw  cotton  or  lint — 
saturated  with  spirits  of  camphor,  laudanum,  sulphuric  ether,  chloro- 
form, creasote,  or  some  one  of  the  essential  oils — may  be  applied. 
The  following  anodyne  application  has  been  employed  with  advantage 
to  relieve  the  pain  arising  from  congestion  of  the  pulp :  Cotton  satu- 
rated with  a  solution  composed  of  alcohol,  1  ounce ;  chloroform,  2 
ounces;  ether,  f  ounce;  gum  camphor,  i  ounce;  tincture  of  opium,  i 
ounce ;  aud  oil  of  cloves,  1  drachm.  When  the  pain  is  relieved 
another  application,  consisting  of  carbolic  acid  and  oil  of  cloves,  is 
made  and  permitted  to  remain  for  some  fifteen  minutes.  A  paste  com- 
posed of  iodoform  and  glycerine  is  also  employed  after  the  active 
symptoms  of  congestion  have  subsided. 

For  the  treatment  of  wounded  and  irritated  pulps  the  tincture  of 
calendula  proves  a  very  useful  remedy.  Such  agents  as  glycerole  of 
thymol,  carvacrol,  oil  of  eucalyptus,  tannic  acid,  lead  water,  morphine, 


ODONTALGIA — TOOTHACHE.  273 

creasote,  chloral,  and  tincture  of  aconite,  have  also  been  found  ser- 
viceable in  the  treatment  of  inflamed  conditions  of  the  pulp. 

When  the  irritation  is  produced  by  acidulated  buccal  fluids,  the  appli- 
cation of  carbonate  of  soda,  or  some  other  alkali — tepid  water  containino- 
suflicient  carbonate  of  soda  to  make  it  slightly  alkaline — will  often  give 
immediate  temporary  relief;  but  as  the  condition  of  the  secretions  of  the 
mouth,  especially  the  salivary,  is  usually  owing  to  gastric  derangement, 
the  correction  of  this  constitutes  the  first  and  most  important  remedial 
indication.  When  any  application  is  made  to  the  pulp  for  the  purpose 
of  removing  irritation  and  pain,  its  full  eflect  will  not  be  obtained  un- 
less the  fluids  of  the  mouth  are  excluded  from  the  cavity  of  the  tooth ; 
this  may  be  done  by  closing  the  orifice  with  softened  wax,  or  cotton 
saturated  with  the  sandarach  solution,  using  the  precaution  not  to 
force  it  so  far  as  to  press  the  application  previously  made  upon  the 
exposed  pulp. 

ODONTALGIA — TOOTHACHE. 

Pain  in  a  tooth,  toothache,  or  odontalgia, "^^  as  it  is  technically  termed, 
is  a  symptom  of  some  functional  or  structural  disturbance,  either  of 
the  organ  in  which  the  pain  is  seated,  or  of  some  other  part  or  parts  of 
the  body,  but  more  frequently  of  the  former  than  of  the  latter.  So 
variable  is  the  character  of  the  sensation,  that  any  description  would 
fail  to  convey  to  one  who  has  never  experienced  it  a  correct  idea  of  its 
nature.  The  pain  sometimes  amounts  only  to  slight  uneasiness ;  at  other 
times  the  agony  is  almost  insupportable.  It  may  be  dull,  deep-seated, 
boring,  throbbing,  or  lancinating.  It  may  be  slight  at  first,  gradually 
increasing  in  severity  until  it  amounts  to  the  most  excruciating  tor- 
ture, or  it  may  come  on  without  any  premonition  whatever.  It  may 
be  confined  to  a  single  tooth,  or  it  may  affect  several  at  the  same  time. 
It  may  commence  in  one  tooth  and  pass  from  thence  to  another,  and 
continue  until  every  one  in  turn  has  been  attacked.  It  may  continue 
for  hours  and  days  with  scarcely  any  cessation  ;  or  it  may  be  intermit- 
tent, the  paroxysms  recurring  at  stated  or  irregular  intervals,  and  each 
lasting  from  thirty  minutes  to  one,  two  or  more  hours. 

CAUSES. 

The  causes  of  toothache  are  almost  as  numerous  as  are  the  varieties 
of  character  which  it  exhibits.  Irritation  and  inflammation  of  the 
pulp,  and  in^ammation  of  the  investing  membrane,  are  among  the 
most  frequent ;  but  it  is  sometimes  referable  to  a  morbid  condition  of 
the  nerve  or  nerves  going  to  a  single  tooth,  or  of  the  trunk  from  which 

*  So  much  has  been  said  upon  this  subject  in  the  consideration  of  the  different 
forms  of  inflammation  of  the  pulp  in  the  preceding  pages,  that  but  little  remains 
to  be  noticed. 

i8 


274  DENTAL  PATHOLOGY,  THEEAPEUTICS. 

several  teeth  are  supplied ;  also  to  derangement  of  the  digestive  or- 
gans, to  increased  nervous  susceptibility  of  the  uterus  resulting  from 
jDregnancy,  amenorrhoea,  etc.,  and  to  certain  diatheses  of  the  general 
system. 

Dr.  Hullihen  enumerates  the  following  as  the  causes  of  toothache ; 
1,  exposure  of  the  pulp ;  2,  fungus  of  the  pulp ;  3,  confinement  of  pus 
in  the  internal  cavity ;  4,  a  diseased  state  of  the  periosteum  covering 
the  root ;  and  5,  sympathy.  Dr.  Heilden  attributes  it  to  congestion 
or  inflammation,  or  to  a  lesion  of  the  nerves  of  the  lining  membrane 
and  pulp,  or  of  the  peridental  membrane. 

Inflammation  of  the  lining  membrane  and  pulp  may  be  produced 
by  a  blow  upon  a  tooth,  or  by  powerful  impressions  of  heat  and  cold 
communicated  through  the  enamel  and  dentine,  or  through  a  metallic 
filling ;  but  it  is  more  frequently  occasioned  by  pressure,  or  by  the 
direct  contact  of  irritating  agents,  such  as  carious  portions  of  the  tooth, 
particles  of  food,  acrid  humors,  and  other  irritating  external  substances. 
But  inflammation  is  not  always  a  necessary  consequence  of  such  im- 
pressions. Pain  may  be  produced  by  them  when  inflammation  does 
not  exist ;  in  this  case  it  usually  subsides  soon  after  the  removal  of  the 
irritant.  Indeed,  the  pulp  of  a  tooth  may  be  exposed  for  months,  and 
subjected  several  times  every  day  to  the  contact  of  foreign  substances, 
wdthout  becoming  the  seat  of  inflammatory  action  ;  and  in  the  absence 
of  this,  the  pain,  though  coming  on  with  the  suddenness  of  an  electric 
flash,  and  often  of  the  most  excruciating  kind,  is  seldom  of  long  du- 
ration. 

But  when  inflammation  exists,  the  pain,  which  at  first  amounts  only 
to  a  slight  gnawing  sensation,  is  more  constant ;  after  a  while  it  as- 
sumes a  throbbing  character,  and  if  not  promptly  arrested,  it  increases 
in  severity,  and  continues  until  suppuration  of  the  lining  membrane 
and  pulp  takes  place.  So  long  as  it  is  confined  to  the  parts  within 
the  pulp  cavity,  the  pain  is  not  increased  by  pressure  on  the  tooth,  nor 
is  the  tooth  started  from  the  socket,  as  in  periodontitis.  The  locality 
of  the  inflammation  may  also  be  distinguished  by  the  fact  that  cold 
water  or  ice  applied  to  the  tooth  generally  gives  relief.  But  the  in- 
flammation rarely  confines  itself  long  to  the  interior  of  the  tooth ;  it 
usually  soon  extends  to  the  periosteum  of  the  root  and  its  socket,  when 
a  somewhat  different  train  of  phenomena  are  develoj)ed.  Suppuration, 
however,  having  taken  place,  an  abscess  soon  forms  at  the  extremity 
of  the  root. 

The  severity  of  the  pain  attending  pulpitis  (as  inflammation  of  the 
pulp  is  technically  termed),  is,  doubtless,  owing  to  the  fact  that  this 
exceedingly  sensitive  structure,  as  its  vessels  become  injected,  is  pre- 
vented from  exjDanding  by  the  unyielding  nature  of  the  walls  of  the 


ODONTALGIA — TOOTHACHE.  275 

cavity  in  which  it  is  situated.  Its  capillaries  being  thus  distended, 
must,  as  a  necessary  consequence,  press  upon  the  nerves  which  are 
everywhere  distributed  through  it,  and  the  excruciatingly  painful, 
throbbing  sensation,  by  which  this  variety  of  toothache  is  characterized, 
is  produced  by  the  pulsation  of  these  vessels.  Hence,  increased  action 
of  the  heart  and  arteries,  from  whatever  cause  produced,  augments  the 
pain  ;  it  is  also,  more  severe  at  night,  while  the  body  is  in  a  recumbent 
posture,  than  during  the  day,  because  this  position  gives  an  increased 
fullness  to  the  arteries  of  the  head.  The  phenomena  attending  the 
inflammation,  however,  are  influenced  very  much  by  the  conditiou  of 
the  tooth  and  the  habit  of  body  of  the  patient. 

When  the  inflammation  is  acute,  it  extends  to  every  part  of  the  pulp 
and  lining  membrane.  It  also  occurs  more  frequently  before  than  after 
these  tissues  have  become  exposed,  and  generally  terminates  in  suppu- 
ration. Chronic  inflammation  usually  arises  from  partial  exposure  of 
the  pulp,  and  may  exist  for  months  without  being  attended  with  pain ; 
but  the  pulp,  when  thus  afiected,  is  more  susceptible  of  injury  by  heat 
or  cold,  and  by  irritating  substances ;  and  the  liability  of  the  tooth  to 
ache,  especially  at  night,  is  greatly  increased. 

Toothache  caused  by  acute  inflammation  of  the  investing  membrane 
is  characterized  by  pain,  at  first  dull,  afterward  acute  and  throbbing, 
soreness  and  elongation  of  the  tooth,  redness  and  tumefaction  of  the 
gums,  and  sometimes  by  swelling  of  the  cheek ;  indicating  the  forma- 
tion of  alveolar  abscess.  In  this  variety  of  odontalgia,  the  tooth  is 
often  so  mucTi  raised  in  its  socket  as  to  interfere  more  or  less  with 
mastication. 

The  pain  attending  the  foregoing  pathological  conditions,  when  se- 
vere and  protracted,  is  often  accompanied  by  constipation,  headache, 
dryness  of  the  skin,  flushed  cheeks,  fullness  and  increased  rapidity  of 
pulse,  and  other  constitutional  symptoms. 

The  nervous  susceptibility  of  the  teeth  is  sometimes  so  much  increased 
by  organic  and  even  functional  disturbances  of  other  and  often  remote 
parts,  that  the  mere  contact  of  the  minute  nerves  of  the  pulp  and  the 
lining  membrane  against  the  wall  of  dentine  which  encases  them  is 
attended  with  severe  pain.  This  variety  of  odontalgia  is  termed  sym- 
pathetic, and  is  supposed  to  be  the  result  of  the  transfer  of  nervous 
irritation,  or  more  properly,  of  exalted  sensibility  of  the  dental  nerves, 
arising  from  a  morbid  condition  or  functional  disturbance  of  some  other 
part.  K  this  hypothesis  be  true,  it  is  probable  that  with  this  height- 
ened nervous  excitability  there  is  a  slight  increase  of  vascular  action 
in  the  pulp,  with  a  corresponding  increase  of  size  in  its  capillaries ;  in 
consequence  of  which,  it  is  fair  to  presume  the  nervous  filaments  sup- 
plying these  tissues  would  be  apt  to  respond  painfully  to  the  undue 


276  DENTAL  PATHOLOGY,  THERAPEUTICS. 

pressure.  Though  pain  arising  from  this  cause  may  have  its  seat  in 
sound  as  Avell  as  in  decayed  teeth,  it  occurs  more  frequently  in  the  latter 
than  the  former,  owing  to  the  fact  that  any  structural  alteration  in  the 
dentine  adds  to  their  already  increased  nervous  excitability. 

Persons  of  highly  excitable  nervous  temperaments,  pregnant  females, 
and  individuals  laboring  under  derangement  of  the  digestive  organs, 
are  particularly  subject  to  this  variety  of  toothache.  Odontalgia,  arising 
from  pathological  conditions  or  functional  disturbances  of  other  parts, 
assumes  a  great  variety  of  forms.  The  pain  may  be  continued,  but 
more  frequently  it  is  periodical ;  it  may  be  confined  to  a  single  tooth, 
or  it  may  attack  half  a  dozen  or  more  at  the  same  time.  It  sometimes 
also  alternates  with  the  paroxysms  of  rheumatism  or  gout,  the  pain  in 
,  such  cases  assuming  the  specific  character  of  these  diseases. 

Mr.  W.,  aged  forty,  for  fifteen  years  the  victim  of  gout,  came  to  me 
in  1830.  The  first  right  upper  molar  was  carious,  but  the  pulp  not 
exposed.  Ten  or  twelve  days  before  each  attack  of  gout,  recurring 
every  three  or  six  months  during  the  last  five  years,  this  tooth  w^as  the 
seat  of  a  peculiar  grinding,  lancinating  pain,  becoming  gradually 
more  severe,  but  ceasing  entirely  as  the  gout  symptoms  came  on ;  it 
returned  as  these  subsided,  and  continued  for  two  weeks.  Filling  the 
tooth  gave  temporary  relief  only,  and  it  was  found  necessary  to  extract  it. 

In  what  is  termed  neuralgic  toothache,  "  the  pain,"  says  Dr.  Wood, 
"  is  usually  of  the  acute  character  ;  sometimes  mild  in  the  beginning, 
gradually  increasing  in  intensity,  and  as  gradually  declining,  but  usu- 
ally very  irregular  ;  at  one  time  moderate,  at  another  severe,  and  occa- 
sionally darting  with  excruciating  violence  through  the  dental  arches. 
Not  unfrequently  it  assumes  a  regular  intermittent  form.  Instead  of 
pain,  strictly  speaking,  the  sensation  is  sometimes  of  that  kind  which 
is  indicated  when  we  say  that  the  teeth  are  on  edge,  and  is  apt  to  be 
excited  by  certain  harsh  sounds,  such  as  that  produced  in  the  filing  of 
a  saw,  or  by  mental  inquietude,  and  by  the  contact  of  acids  or  other 
irritant  substances.  Neuralgic  toothache  sometimes  persists,  with 
intervals  of  exemption,  for  a  great  length  of  time.  The  diagnosis  is 
occasionally  diflScult.  When,  however,  it  occurs  in  sound  teeth,  is  par- 
oxysmal in  its  character,  is  attended  with  little  or  no  swelling  of  the 
external  parts,  occupies  a  considerable  portion  of  the  jaw,  and  especi- 
ally when  it  alternates  or  is  associated  with  pain  of  the  same  character 
in  other  parts  of  the  face,  there  can  be  little  doubt  as  to  its  real  nature." 
This  variety  of  sympathetic  toothache  is  perhaps  induced  by  caries,  or 
by  the  manner  in  which  the  teeth  are  arranged  in  the  alveolar  arch, 
or  by  some  peculiar  susceptibility  of  the  parts ;  as  is  shown  by  the  fact 
that  the  pain  usually  ceases  on  the  removal  of  all  such  causes  of  irri- 
tation. 


ODONTALGIA — TOOTHACHE.  277 

But  while,  on  the  one  hand,  pain  in  the  teeth  may  be  caused  by  a 
morbid  condition  of  other  organs,  these  organs,  on  the  other  hand, 
frequently  sympathize  with  the  diseased  condition  of  the  teeth,  and 
become,  to  quote  the  language  of  Mr.  Bell,  "  the  apparent  seat  of  pain. 
I  have  seen  this  occur  not  only  in  the  face,  over  the  scalp,  in  the  ear, 
and  underneath  the  lower  jaw,  but  down  the  neck,  over  the  shoulder, 
and  along  the  whole  length  of  the  arm."  Gases  of  this  sort  are  fre- 
quently met  with. 

In  treating  of  toothache,  Dr.  Good  observes :  "  This  is  often  an  idio- 
pathic  affection,  dependent  upon  a  peculiar  irritability  (from  a,  cause 
we  cannot  easily  trace)  of  the  nerves  subservient  to  the  aching  tooth, 
or  of  the  tunics  by  which  it  is  covered,  or  of  the  periosteum,  or  the 
fine  membrane  that  lines  the  interior  of  the  alveoli.  But  it  is  more 
frequently  a  disease  of  sympathy,  produced  by  pregnancy,  or  chronic 
rheumatism,  or  acrimony  in  the  stomach,  in  persons  of  an  irritable 
habit.  It  is  still  less  to  be  wondered  at  that  the  nerves  of  the  teeth 
should  often  associate  in  the  maddening  pain  of  facial  neuralgia,  or 
tic  douloureux,  as  the  French  writers  sometimes  term  it ;  for  here  the 
connection  is  both  direct  and  immediate.  In  consequence  of  this,  the 
patient,  in  most  instances,  regards  the  teeth  themselves  as  the  salient 
points  of  pain  (as  they  unquestionably  may  be  in  some  cases),  and 
rests  his  only  hope  of  relief  upon  extraction  ;  but  when  he  applies  to 
the  operator,  he  is  at  a  loss  to  fix  upon  any  particular  tooth.  Mr. 
Fox  gives  a  striking  example  of  this,  in  a  person  from  whom  he  ex- 
tracted a  tooth  which  afforded  little  or  no  relief;  in  consequence  of 
which  his  patient  applied  to  him  ouly  two  days  afterward  and  requested 
the  removal  of  several  adjoining  teeth,  which  were  perfectly  sound. 
This  he  objected  to,  and  suspecting  the  real  nature  of  the  disease,  he 
immediately  took  him  to  Sir  Astley  Cooper,  who,  by  dividing  the  affected 
nerve,  produced  a  radical  cure  in  a  few  days."  The  author  is  acquainted 
with  a  gentleman  similarly  affected.  He  has  had  all  his  teeth  on  the 
right  side  of  both  jaws  extracted,  without  obtaining  any  relief. 

There  is  still  another  cause  of  toothache,  which  we  should  not  omit 
to  mention — exostosis ;  but  from  the  obscurity  of  the  diagnosis,  the 
existence  of  the  affection  can  seldom  be  determined  with  positive  cer- 
tainty, except  by  the  removal  of  the  tooth.  As  we  have  already  had 
occasion  to  treat  of  this  disease,  it  is  unnecessary  in  this  place  to  dwell 
upon  the  subject. 

Finally,  some  teeth,  from  peculiar  constitutional  idiosyncrasy,  are 
more  liable  to  odontalgia  than  others.  It  sometimes  happens  that 
every  tooth  in  the  mouth  is  destroyed  by  caries  without  being  affected 
with  pain,  while  at  other  times  teeth  apparently  sound  become  the  seat 
of  the  most  agonizing  torture. 


278  DENTAL  PATHOLOGY,  THERAtEUTtCS. 

TREATMENT. 

The  first  thing  to  be  attended  to  in  the  treatment  of  toothache  is 
the  removal  of  the  causes  which  have  given  rise  to  it ;  this  can  only 
be  done  by  carrying  out  the  curative  and  remedial  indications  of  the 
morbid  conditions  and  functional  disturbances  with  which  it  is  con- 
nected. While  these  continue,  it  will  be  impossible  to  obtain  perma- 
nent relief.  The  sensibility  of  the  nerves  supplying  a  tooth  may  often 
be  obtunded,  and  the  pain  palliated  by  the  application  of  stimulating 
and  anodyne  agents  to  the  exposed  pulp ;  but  the  relief  thus  procured 
is  seldom  of  long  duration.  When  their  eflFects  subside,  the  pain  usu- 
ally returns  with  increased  severity.  When  the  pain  arises  from  chronic 
inflammation  and  irritation,  produced  by  external  agents  on  an  exposed 
portion  of  the  lining  membrane,  such  applications  may  often  be  em- 
ployed with  great  advantage :  and  among  those  which  have  been  used 
for  this  purpose  are  creasote,  the  oil  of  cloves,  cinnamon,  etc.,  laudanum, 
spirits  of  camphor,  tannin,  ether,  and  chloroform.  But  of  all  the 
remedies  prescribed  by  the  author,  he  has  found  none  more  useful  in 
allaying  the  pain  than  the  following : — 

Sulphuric  etber ^j  Sulphuric  ether ^j 

Powdered  camphor gij  Creasote ^ss 

Powdered  alum ^ij  Ext.  of  nutgalls .^j 

Sulphate  of  morphine gr- ij.  Powdered  camph gss. 

The  alum  should  be  very  finely  powdered,  and  all  the  ingredients  well  mixed 
before  use. 

After  removing  all  foreign  matter  and  carefully  drying  the  cavity 
of  the  tooth,  a  small  bit  of  cotton  or  lint  dipped  in  either  of  the 
above  mixtures  may  be  applied,  and  renewed  several  times  a  day,  if 
necessary.  The  relief  obtained  is,  in  the  majority  of  cases,  almost 
instantaneous  ;  but,  as  the  effect  is  only  temporary,  the  pain  is  apt  to 
recur.  The  author  has  sometimes  used  a  thick  solution  of  gutta-percha 
in  chloroform.  The  application  of  a  drop  or  two  of  this  to  the  ex- 
posed pulp  is  usually  followed  by  the  immediate  cessation  of  pain, 
and  as  the  chloroform  evaporates,  a  thin  layer  of  gutta-percha  remains, 
and  serves  for  a  time  as  a  sort  of  protection  to  the  pulp. 

It  often  becomes  necessary  to  have  recourse  to  the  destruction  of  the 
pulp,  as  there  are  many  cases  in  which  the  patient  cannot  be  prevailed 
upon  to  submit  to  the  former,  and  as  there  are  others  in  which  the 
retention  of  the  organ  is  called  for  by  some  peculiar  necessity.  This 
may  be  effected  either  by  immediate  extirpation  with  a  small,  sharp- 
pointed  elastic  stilet  or  probe,  by  the  actual  cautery,  arsenious  acid, 
carbolic  acid,  cobalt,  or  chloride  of  zinc.  Immediate  extirpation,  or 
the  application  of  devitalizing  agents,  are  the  means  usually  employed 
for  the  purpose. 


ODONTALGIA — TOOTHACHE.  279 

Pain  in  a  tooth  arising  from  acute  inflammation  of  the  pulp  and 
lining  membrane,  can  only  be  relieved  by  the  extraction  of  the  tooth, 
the  destruction  of  the  pulp,  or  by  subduing  the  inflammatoiy  action  ; 
the  last  can  seldom  be  done  except  by  the  most  energetic  treatment  in 
the  very  beginning,  in  cases  where  the  decay  has  not  penetrated  to  the 
pulp  cavity.  The  propriety  or  impropriety  of  extraction  will  be  de- 
termined by  the  amount  of  pain,  the  j^rogress  made  by  the  inflamma- 
tion, the  condition  of  the  parts  with  which  the  tooth  is  immediately 
connected,  the  efiect  of  the  local  disturbance  upon  the  general  system, 
the  situation  and  importance  of  the  tooth,  and  the  extent  of  structural 
alteration  which  has  taken  place  in  the  crown.  If  the  retention  of  the 
tooth,  on  account  of  its  location,  or  the  loss  of  several  other  teeth,  is  of 
great  importance  to  the  patient,  and  the  circumstances  of  the  case  jus- 
tify a  well-grounded  belief  that  it  can  be  preserved  and  rendered  useful, 
without  acting  as  a  morbid  irritant,  the  operation,  if  possible,  should 
be  avoided.  In  this  case,  supposing  the  inflammation  to  have  proceeded 
too  far  to  be  arrested,  the  pulp  may  be  destroyed  and  the  tooth  treated 
in  the  manner  described  in  another  chapter. 

When  the  inflammation  is  produced  by  other  causes  than  exposure 
of  the  pulp  and  the  contact  of  external  irritants,  it  may  perhaps  be 
successfully  combated.  The  treatment  is  similar  to  that  for  local  in- 
flammation in  other  parts  of  the  body ;  the  administration  of  saline 
cathartics,  the  application  of  leeches  to  the  gum  of  the  affected  tooth, 
abstinence  from  animal  food  and  stimulating  drinks.  If  the  pulse  is 
full  and  hard,  blood  may  be  taken  from  the  arm  with  advantage. 
Diaphoretics  are  often  beneficial,  such  as  Dover's  Powder,  or  Spirit  of 
Mindererus.  Bromide  of  potassium,  in  doses  of  gr.  v  to  gr.  xl,  with  a 
mustard  plaster  to  the  back  of  neck  and  a  hot  foot-bath,  will  also  be 
found  efficacious.  Should  these  means  fail  to  arrest  the  inflammation, 
and  suppuration  take  place,  the  formation  of  alveolar  abscess  may  be 
prevented  by  promptly  perforating  the  crown  of  the  tooth  for  the 
escape  of  the  matter;  but  such  cases  usually  terminate  in  periodon- 
titis, which  perhaps  arises  as  frequently  from  this  as  from  any  other 
cause. 

As  the  treatment  of  periodontitis  or  inflammation  of  the  investing 
membrane  is  described  in.  another  chapter,  it  is  unnecessary  to  repeat 
it.  But  when  the  formation  of  alveolar  abscess  is  threatened,  the 
removal  of  the  tooth,  in  many  cases,  will  be  found  necessary.  If  it  be 
an  incisor  or  cuspid,  however,  the  operation  should  be  performed  as  a 
last  resort. 

Toothache  assuming  a  rheumatic  or  gouty  character  calls  for  a  some- 
what different  plan  of  treatment.  In  addition  to  the  local  means 
already  described,  it  may  be  necessary  to   adopt   the   constitutional 


280  DENTAL   PATHOLOGY,  THERAPEUTICS. 

treatment  applicable  to  rheumatism  and  gout.  When  the  pain  arises 
from  increased  vascular  action  and  nervous  irritation  of  the  pulp,  oc- 
casioned by  a  disordered  condition  of  the  digestive  organs,  and  assumes 
an  intermittent  form,  an  emetic  or  cathartic,  followed  by  the  use  of 
quinine,  will  generally  afford  relief,  provided  caries  has  not  penetrated 
to  the  pulp  cavity.  If  dependent  on  general  nervous  irritability  of 
the  system,  tonics,  exercise,  change  of  air,  or  such  other  constitutional 
measures  as  the  peculiarities  of  the  case  may  indicate,  should  be  recom- 
mended. 

The  extraction  of  the  tooth  is  the  only  remedy  that  can  be  relied 
upon  for  relief  of  pain  arising  from  exostosis  of  the  root.  Dr.  Good, 
however,  thinks  it  may  be  cured  in  the  early  stages  by  the  use  of 
leeches  and  mercurial  ointment,  and  others  recommend  the  internal 
use  of  iodide  of  potassium. 

SPONTANEOUS   DISORGANIZATION. 

The  spontaneous  destruction  of  the  pulp  of  a  tooth  is  an  affection  which 
seems  to  have  been  entirely  overlooked  by  writers  on  dental  pathology ; 
and,  although  it  is  one  which  rarely  occurs,  examples  of  it  are  met  with 
suflBciently  often  to  entitle  it  to  a  place  among  the  diseases  of  the  teeth. 
The  first  case  which  attracted  the  attention  of  the  author  occurred  in 
1836,  and  he  has  subsequently  met  with  six  or  seven  others.  In  each 
of  them  the  disorganization  had  been  carried  on  so  insidiously,  that 
neither  the  presence  of  disease  nor  structural  alteration  was  suspected, 
until  the  teeth  had  assumed  a  dull  brownish  or  bluish-brown  appear- 
ance. The  death  of  the  pulp  had  not  been  preceded  in  any  of  these 
cases  by  the  slightest  indication  of  inflammatory  action.  It  had  appa- 
rently resulted  from  want  of  sufficient  vital  energy  to  sustain  the 
nutritive  function. 

The  sockets  of  the  affected  teeth  in  these  cases  were,  seemingly,  in 
a  healthy  condition — a  circumstance  which,  when  we  take  into  con- 
sideration that  the  parts  of  the  extremity  of  the  roots  were  exposed  to 
the  action  of  the  disorganized  remains  of  the  dental  pulps,  may  appear 
somewhat  strange.  But  this  may  have  been  owing,  partly,  to  dimin- 
ished excitability  in  the  alveolo-dental  periosteum,  and  partly  to  the 
smallness  of  the  quantity,  and  the  innocuous  character  of  the  matter 
contained  in  the  central  cavities  of  the  teeth.  The  gums  of  that  portion 
of  the  alveolar  border  occupied  by  the  affected  teeth  had  a  pale,  gray- 
ish-purple appearance,  but  exhibited  no  indications  of  actual  disease. 
They  were  as  thin  and  their  margins  as  distinctly  festooned  here  as  in 
any  other  part  of  the  mouth.  In  some  instances,  the  teeth  had  been 
irt  this  condition  for  seven  or  eight  years.  On  perforating  the 
crowns,  only  a  drop  of  dark-brown  matter,  about  the  consistence  of 


FUNGOUS   GEOWTH.  281 

thin  cream,  and  having  but  little  odor,  escaped  from  the  pulp  cavity 
of  each. 

In  all  the  cases  which  the  author  has  seen  of  this  remarkable  affec- 
tion, the  loss  of  vitality  had  taken  place  previously  to  the  twentieth 
year  of  age,  and,  according  to  his  observations  upon  the  subject,  it 
seldom  confines  itself  to  a  single  tooth,  but  occurs  simultaneously  in 
corresponding  teeth.  The  pulps  of  several  usually  perish  at  about  the 
same  time.  In  the  first  case  to  which  his  attention  was  called,  six  had 
lost  their  vitality.  The  aflTection,  too,  seems  to  be  principally  confined 
to  the  incisors  and  cuspids,  and  sound  teeth  appear  to  be  as  subject  to 
it  as  those  which  are  carious. 

Now,  as  the  disorganization  of  the  pulp,  in  cases  of  this  sort,  is  not 
the  result  of  inflammatory  action,  it  must  be  dependent  upon  consti- 
tutional rather  than  local  causes — upon  some  peculiar  cachexia,  which 
causes  the  function  of  sanguinification  to  be  imperfectly  performed. 
This  inference,  too,  seems  to  be  fully  warranted  by  the  appearance  of 
the  subjects  in  all  the  cases  which  the  author  has  had  an  opportunity 
of  examining — characterized  by  an  extremely  pale  and  slightly  bloated 
aspect  of  countenance,  indicating  a  serous  condition  of  blood. 

The  remedial  indications  in  cases  of  this  sort  are  the  same  as  in 
necrosis  produced  by  inflammation  and  suppuration  of  the  lining  mem- 
brane and  pulp. 

FUNGOUS    GROWTH. 

The  pulp  of  a  tooth,  when  exposed  by  decay  of  the  crown,  some- 
times becomes  the  seat  of  a  fungous  growth,  in  the  form  of  a  small 
vascular  tumor.  These  morbid  growths  sometimes  attain  the  size  of  a 
large  pea,  completely  filling  the  cavity  made  in  the  crown  of  the  tooth 
by  decay  ;  at  other  times  they  do  not  exceed  that  of  a  small  elderberry. 
The  former  have  little  sensibility,  and  bleed  freely  from  the  slightest 
injury;  the  latter  are  less  vascular,  but  are  nearly  as  sensitive  as  the 
pulp  in  a  healthy  state. 

It  often  happens  that  a  fungous  growth  of  the  gum  or  dental  peri- 
osteum, finding  its  way  through  an  opening  in  the  side  of  the  neck  or 
root  of  a  decayed  tooth,  appears  in  the  central  cavity,  and  is  sometimes 
mistaken  for  a  morbid  growth  of  the  pulp.  Such  tumors  usually  grow 
very  fast,  and  sometimes  attain  the  size  of  a  hickory  nut.  They  are 
exceedingly  vascular,  bleeding  profusely  when  wounded,  and  are  soon 
reproduced  after  removal.  The  author  has  met  with  tumors  of  this 
kind  which  had  originated  in  the  alveolo-defital  periosteum  of  the 
extremity  of  the  root. 

The  only  remedy  in  such  cases  is  the  removal  of  the  tooth.  A  cure 
cannot  be  effected  by  extirpating  the  morbid  growth.  The  author  has 
frequently  removed  them  nearly  to  the  extremity  of  the  root,  but  they 


282  DENTAL  PATHOLOGY,  THERAPEUTICS. 

have  always  reappeared  in  a  few  days  or  weeks  after  the  operation. 
Even  if  a  return  of  the  disease  could  be  prevented,  the  extraction  of 
the  tooth  should  be  insisted  on,  as  all  teeth  in  which  tumors  of  this 
sort  are  situated  are  morbid  irritants,  and  cannot  remain  without 
detriment  to  the  health  of  the  parts  with  which  they  are  in  immediate 
connection. 

Where  there  is  a  tendency  to  fungous  growth  of  the  pulp,  the  appli- 
cation of  an  escharotic  has  proved  serviceable.  Of  these  agents  chromic 
acid  appears  to  be  very  effective. 

Another  method  is  to  apply  carbolic  acid  freely  to  the  fungous 
growth,  to  obtund  its  sensitiveness,  excise  it,  and  then  make  an  appli- 
cation of  nitric  acid  on  a  disk  of  card-board.  It  frequently  happens, 
however,  that  teeth  in  this  condition  are  too  far  gone  to  justify  their 
retention. 

OSSIFICATION. 

Allusion  has  been  made  several  times,  in  the  course  of  this  work,  to 
the  ossification  of  the  dental  pulp,  as  a  means  employed  by  nature  to 
prevent  the  exposure  of  this  most  delicate  and  exquisitely  sensitive 
structure.  But  examples  of  it  are  occasionally  met  with  in  teeth 
which  have  suffered  no  loss  of  substance,  either  from  mechanical  or 
spontaneous  abrasion,  or  from  the  decay  of  the  dentine.  The  occur- 
rence, whatever  may  be  the  circumstances  under  which  it  takes  place, 
is  evidently  the  result  of  the  operation  of  an  established  law  of  the 
economy,  dependent  upon  moderate  irritation  and  a  slight  increase  of 
vascular  action  ;  ossification  having  commenced,  it  usually  goes  on 
until  every  part  of  the  pulp  is  converted  into  a  substance  analogous  to 
cementum.  We  infer,  then,  that  when  the  pulp  of  a  tooth  becomes  the 
seat  of  a  sufficient  amount  of  irritation,  ossification  must  follow  as  a 
necessary  consequence ;  but  if  the  irritation  be  succeeded  by  active 
inflammation,  a  different  result  may  be  expected. 

The  irritation  necessary  for  the  ossification  of  the  pulp  of  a  tooth 
sometimes  arises  from  constitutional  causes  ;  but  in  the  majority  of 
cases,  it  results  from  the  action  of  local  irritants,  and  most  frequently 
from  impressions  of  heat  and  cold,  communicated  through  the  medium 
of  a  metallic  filling  or  a  thin  layer  of  dentine. 

During  the  ossification,  a  sensation  is  occasionally  experienced  in 
the  tooth  somewhat  similar,  though  altogether  less  in  degree,  to  that 
which  attends  the  knitting  of  the  fractured  extremities  of  a  broken 
bone.  A  numb,  vibratory  pain,  barely  perceptible,  is  first  felt  passing 
through  the  tooth  several  times  a  day,  but  only  lasting  a  second  or  two 
at  a  time.  It  is  often  scarcely  sufficient  to  occasion  any  annoyance,  or 
to  attract  anything  more  than  momentary  attention. 

As  the  ossified  deposit  increases  in  size,  pain  of  a  neuralgic  character 


DESTRUCTION   AND   REMOVAL   OF   THE   PULP.  283 

may  ensue,  and  similar  to  the  sensation  which  results  from  the  knitting 
together  of  the  fractured  extremities  of  a  bone,  but  not  constantly  severe. 
At  times,  however,  the  pain  becomes  sharp  and  darting,  affect- 
ing  the  side  ofthe  face  and  head.  The  treatment  consists  in  the 
application  of  an  anodyne,  such  as  lead  water,  about  the  affected 
root  and  the  opening  of  the  pulp  chamber,  in  order  to  remove 
the  affected  pulp,  which  should  be  completely  extirpated. 

With  the  ossification  ofthe  pulp,  the  crown  and  inner  walls 
of  the  root  lose  their  vitality,  but  the  appearance  of  the  tooth 
is  not,  as  in  the  case  of  necrosis  arising  from  the  disorganiza- 
tion of  the  pulp,  materially  affected.  The  central  cavity  being 
filled  with  semi-translucent  osteo-dentine,  the  crown  retains 
its  natural  color.  The  discoloration  and  opacity  attending 
necrosis  produced  by  other  causes  result  partly  from  the 
presence  of  putrid  matter  in  the  pulp  cavity,  and  partly  from 
its  absorption  by  the  surrounding  dentinal  wall. 

DESTRUCTION   AND   REMOVAL   OF   THE   PULP. 

With  regard  to  the  best  means  of  destroying  the  pulp  of 
the  tooth,  when  it  is  impossible  to  preserve  it,  there  exists 
much  diversity  of  opinion.  There  are  two  methods  by  which 
this  may  be  accomplished,  one  by  immediate  extirpation  with 
an  instrument,  and  by  actual  cautery ;  the  other,  by  the  appli- 
cation of  some  devitalizing  agent,  as  arsenic.  Each  method 
has  its  advocates. 

For  the  removal  of  the  pulp  by  extirpation,  there  are  dif- 
ferent forms  of  instruments  employed,  such  as  a  three-  or  four- 
sided  broach,  barbed  for  some  distance  from  the  point,  which 
is  thrust  as  far  up  the  pulp  canal  as  is  possible,  then  rotated 
and  withdrawn,  bringing  the  pulp  with  it.  Fig.  91  represents 
a  broach  of  this  kind,  which  may  be  used  with  or  without  a 
holder.  Another  form  of  broach  is  used  for  this  operation 
which  is  not  barbed,  but  thrust  into  the  pulp  for  the  purpose  of 
so  lacerating  it  that  it  may  afterward  be  removed  with  nerve 
instruments  without  much  pain.  A  fine,  round  steel  wire, 
from  which  the  temper  has  been  drawn,  and  having  a  flat 
point  bent  on  an  angle  of  about  forty  degrees,  is  also  used  for 
extirpating  the  pulp. 

The  edge  of  the  point,  in  introducing  this  instrument,  is 
pressed  against  one  wall  of  the  canal  and  gradually  forced 
up  as  far  as  it  will  enter,  when  it  is  suddenly  turned  so  as  to 
excise  the  pulp,  and  on  withdrawing  the  instrument  bring  the 
severed  organ  with  it. 


284  DENTAL  PATHOLOGY,  THERAPEUTICS. 

For  extirpating  the  pulps  of  the  molar  teeth,  a  larger  instrument 
is  required,  which  is  thrust  into  the  pulp  chamber  and  rotated  so  as 
to  sever  the  body  of  the  pulp  from  the  branches  filling  the  root 
canals.  The  small  nerve  instruments  are  then  employed  for  remov- 
ing these  branches. 

The  operation  of  extirpation  should  depend  upon  the  temperament 
of  the  patient,  and  the  condition  and  class  of  the  tooth.  Where  such 
an  operation  would  cause  a  severe  shock,  owing  to  a  nervous,  irritable 
temperament,  it  is  best  to  employ  the  therapeutical  method  ;  on  the 
other  hand,  where  there  is  great  power  of  endurance,  and  the  tooth  is 
of  a  frail,  chalky  consistence,  or  threatened  with  periosteal  inflam- 
mation, it  is  preferable  to  remove  the  pulp  by  an  operation.  The 
pain,  however,  can  be  greatly  mitigated  by  the  previous  application  of 
some  obtunding  agent,  such  as  sulphate  of  atropine,  aconite,  or  chloro- 
form. 

In  all  cases,  and  by  whatever  method,  the  orifice  of  exposure  should 
be  large,  and  nearly  on  a  line  with  the  axis  of  the  tooth,  so  as  to 
admit  of  easy  manipulation,  especially  if  the  barbed  broach  or  bent 
wire  are  employed  ;  and  when  a  pulp  is  removed  by  such  an  operation, 
the  wound  usually  heals  by  first  intention,  and  no  periosteal  irritation 
results. 

The  actual  cautery  consists  in  thrusting  a  wire,  heated  to  a  white 
heat,  up  the  canal ;  but  as  this  is  considered  a  barbarous  method,  it 
is  not  resorted  to  by  practitioners  in  this  country.  Besides,  periosteal 
inflammation  is  often  a  result  of  its  use,  and  the  pain  following  its 
application  is  sometimes  very  severe.  The  galvanic  cautery  is  prefer- 
able to  the  actual  cautery  for  the  destruction  of  pulps,  applied  by 
means  of  a  bent  platinum  wire  maintained  at  a  white  heat. 

ArSenious  acid  *  has  long  been  used  in  connection  with  acetate  of 
morphine  and  creasote,  or  carbolic  acid,  to  devitalize  the  pulp;  the 
arsenic  and  morphine  being  mixed  in  equal  parts,  and  taken  up  on  a 
small  pellet  of  cotton  saturated  with  creasote,  which  is  introduced  di- 
rectly upon  the  exposed  portion  of  the  pulp,  and  the  cavity  filled  with 
wax  or  cotton  saturated  with  a  solution  of  gum  sandarach  and  alcohol. 
The  morphine  was  formerly  supposed  to  modify  the  irritating  action  of 
the  arsenious  acid;  but  since  this  has  been  discovered  not  to  be  the 
case,  its  use  has  been  dispensed  with  by  many.  Water,  alcohol,  and 
ether  are  employed  as  substitutes  for  the  creasote,  and  in  some  cases 

*  The  employment  of  arsenious  acid  for  the  destruction  of  an  exposed  dental 
pulp,  and  the  relief  of  the  pain  arising  therefrom,  originated  with  the  late  Dr. 
Spooner,  of  Montreal ;  and  in  1835  it  was  recommended  to  the  profession  by  his 
brother,  Dr.  S.  Spooner,  of  New  York,  in  an  excellent  popular  treatise  upon 
the  teeth. 


DESTEUCTION   AND   REMOVAL   OF   THE    PULP.  285 

are  preferable.  The  arsenious  acid  is  at  times  combined  with  an  equal 
part  by  weight  of  pulverized  charcoal,  on  account  of  the  antiseptic 
properties  of  this  latter  agent,  and  also  on  account  of  its  mechanical 
action  in  preventing  the  dentine  from  absorbing  what  is  intended  for 
the  pulp  alone.  A  favorite  mixture  is  known  as  ''  nerve  paste ;"  but 
when  a  definite  quantity  of  the  arsenious  acid  is  desired  for  apjDlication 
to  a  pulp,  it  is  better  to  employ  the  dry  form.  Various  formulas  are 
in  use  for  the  preparation  of  devitalizing  mixtures,  such  as  equal  parts 
by  weight  of  arsenious  acid  and  acetate  of  morphine ;  three  parts  by 
weight  of  arsenious  acid  to  two  parts  of  morphine ;  two  parts  of  arse- 
nious acid  and  one  part  of  morphine.  Creasote,  or  carbolic  acid,  is 
generally  employed  to  combine  the  ingredients,  and  also  to  act  as  a 
sedative.  The  thirtieth  part  of  a  grain  of  arsenious  acid  is  the  average 
quantity  employed  to  devitalize  the  pulp.  The  length  of  time  the 
preparation  should  be  allowed  to  remain  varies  from  six  to  twenty-four 
hours.     Dr.  J.  F.  Flagg  recommends  the  following  formula : — 

R.     Arsenious  acid gr.  j 

Acetate  of  morphine gr.  ij 

Carbolic  acid gtt.  iij. 

When  arsenious  acid  is  applied  to  temporary  teeth,  it  is  well  to  use 
one  part  of  arsenic  to  two  parts  of  acetate  of  morphine,  as  an  excess  of 
the  former  agent  might  be  absorbed  by  the  very  vascular  tooth  and 
injure  the  surrounding  membranes.  Not  unfrequently  cases  are  met 
with  where  repeated  applications  of  the  preparation  fail  to  destroy  the 
vitality  of  the  pulp,  which  is  doubtless  owing,  in  cases  where  the  organ 
is  fairly  exposed,  to  its  congested  condition  at  the  time  the  application 
is  made,  which  enables  it  to  resist  the  absorbent  action  of  the  arsenic. 
In  such  cases  a  preparation  composed  of  tannin  and  creasote  has 
proved  serviceable. 

The  time  the  arsenious  acid  is  permitted  to  remain  in  the  tooth  is 
important,  and  should  be  determined  by  the  condition  of  the  pulp,  the 
class  of  tooth,  the  structure  of  the  tooth,  the  age  of  the  patient,  and 
the  susceptibility  to  the  influence  of  the  agent.  The  time  necessary 
for  the  action  of  arsenious  acid  varies  from  six  to  twelve,  and  in  some 
cases  twenty-four  hours. 

To  the  use  of  arsenic  and  all  similar  agents,  the  late  Dr.  liarwood, 
of  Boston,  was  strongly  opposed.  He  states,  in  a  letter  to  the  author, 
that  "  they  cause  death  and  sloughing  in  the  parts  to  which  they  are 
more  immediately  applied,  and  irritation  and  unmanageable  trouble  in 
the  parts  next  beyond  those  they  absolutely  kill.  In  other  words,  they 
irritate  the  parts  beyond  the  dental  cavity,  and  from  this  cause  (and 
perhaps  from  chemical  injury  to  the  tooth  itself)  the  periosteum  of  the 


286  DENTAL  PATHOLOGY,  THERAPEUTICS. 

root  and  socket  becomes  the  seat  of  great  and  frequently  of  un- 
controllable difficulty."  Entertaining  these  views,  he  regards  the 
use  of  such  means  as  opposed  both  to  experience  and  sound 
philosophy,  and  adopts,  without  knowing  that  the  same  thing  had 
been  done  by  others,  what  he  believes  to  be  a  more  correct  practice — 
immediate  extirpation.  He  thus  describes  his  method  of  accom- 
plishing this  object : — 

"  I  first  efiect  such  an  opening  as  will  enable  me  to  approach  the 
exposed  pulp  in  the  line  of  its  axis,  or  as  nearly  so  as  circumstances 
will  permit.  Then,  having  carefully  but  sufficiently  exposed  the  sur- 
face of  the  pulp,  I  pass  down  to  the  apex  of  the  root,  through  the  pulp, 
a  small  untempered  steel  instrument,  with  a  trocar-shaped  point,  and 
revolving  it  once  or  twice  sever  the  vessels  and  nerve.  This,  as  any  one 
knows  who  is  accustomed  to  inserting  artificial  teeth,  produces  but  a 
slight  and  momentary  pain.  I  then,  by  means  of  minute  instruments, 
adapted  to  the  purpose,  endeavor  to  remove  every  portion  of  the  severed 
pulp  and  lining  membrane,  and,  as  soon  as  the  hemorrhage  ceases,  dry 
and  fill  the  cavity. 

"  It  should  be  borne  in  mind,  that  at  the  point  where  the  vessels  and 
nerve  in  question  enter  the  root,  the  passage  is  much  smaller  than  it  is 
immediately  within.  This  strait  will  be  easily  recognized  when  reached, 
by  the  touch,  the  instrument  appearing  to  be  arrested  by  an  obstacle, 
and  not  by  being  wedged  in  a  narrow  passage.  Care  should  be  taken, 
I  think,  that  the  instrument  is  not  allowed  to  pass  through  the  strait, 
either  by  being  too  small,  or  by  being  revolved  there  till  it  cuts  its  way 
through.  For,  by  wounding  the  parts  without  the  tooth,  and  forcing 
particles  of  bone  out  upon  the  parts  external  to  the  root,  the  danger  of 
an  unfavorable  result  would  be  greatly  increased." 

Dr.  Harwood  adds,  in  conclusion,  that  he  believes  it  is  better  to  make 
the  division  of  the  parts  a  little  within  the  strait,  though  he  does  not 
regard  the  matter  as  being  yet  fully  settled  by  observation  and  expe- 
rience. As  to  the  success  of  the  practice,  he  speaks  very  confidently  ; 
not  having  had  a  case  treated  in  this  manner,  where  the  patient  and 
pulp  were  healthy,  in  which  there  has  been  a  single  symptom  of  alveolar 
abscess. 

Dr.  E.  J.  Dunning  says :  "  The  destruction  of  the  nerve  by  me- 
chanical means  has  been  practiced  to  a  small  extent  by  dental  surgeons 
for  many  years  ;  but  on  account  of  the  severe  pain  which  in  many  cases 
attends  it,  as  well  as  from  the  fact  that,  in  the  manner  in  which  it  has 
generally  been  practiced,  it  has  proved  no  more  successful  than  other 
and  less  severe  methods,  it  has  been  considered  rather  in  the  light  of  a 
dernier  ressort."  This  he  believes  to  be  owing  to  the  fact  that  the 
nerve  is  often  only  punctured  and  lacerated,  and  afterward  shut  up  in' 


DESTRUCTION   AND   EEMOVAL   OF   THE   PULP.  287 

the  tooth  and  left  to  decompose.   To  prevent  which,  he  says,  "the  whole 
nerve  should  be  removed,  and  its  place  filled  with  gold." 

When  the  nerve  has  been  destroyed  in  the  manner  above  described, 
Dr.  Dunning  says  that  the  operation,  so  far  as  he  has  been  able  to  ob- 
serve, has  been  successful  in  every  case. 

On  the  different  methods  of  destroying  the  nerve.  Dr.  J.  H.  Foster 
says :  "  It  is  a  difficult  matter,  and  I  have  generally  found  it  utterly 
futile,  to  attempt  to  induce  patients  to  submit  to  the  removal  of  the  pulp 
by  extraction  or  excision  with  instruments,  in  those  cases  in  which  it  be- 
comes necessary  to  destroy  vitality  before  the  teeth  can  be  filled.  To 
obtain  the  consent  of  the  patient  by  a  representation  of  the  advantages, 
in  its  immediate  effects,  of  this  mode  of  treatment  by  extirpation  as 
contrasted  with  the  more  slow  and  uncertain  practice,  by  the  aid  of 
chemical  agents,  has  been  my  earnest  endeavor.  I  do  not  remember  a 
single  case  of  the  removal  of  the  dental  pulp  by  an  instrument — the 
gold  being  inserted  into  the  dental  cavity  immediately  after  the  hem- 
orrhage has  been  checked — which  has  resulted  in  alveolar  abscess." 

Dr.  Foster,  however,  generally  employs  arsenious  acid,  with  morphine, 
one  part  of  the  former  to  four  of  the  latter,  applied  on  a  small  pellet 
moistened  with  creasote.  After  applying  this  directly  over  the  pulp, 
he  covers  it  with  a  cap,  to  avoid  pressure ;  then  fills  the  external  cavity 
with  some  soft  material  which  will  exclude  moisture.  At  the  end  of 
forty-eight  hours  he  enlarges  the  dental  cavity,  removing  its  contents 
to  the  apex  of  the  root :  then,  after  waiting  another  forty-eight  hours, 
he  proceeds  to  fill  the  canal,  leaving  the  cavity  in  the  crown  to  be  filled 
at  a  subsequent  sitting. 

In  performing  this  operation  on  molar  teeth,  where  there  is  a  prob- 
able chance  of  a  favorable  issue,  and  the  preservation  of  these  teeth  is 
particularly  called  for,  he  thinks  it  important  that  the  excavation 
should  be  done  at  intervals,  so  as  to  cause  as  little  irritation  at  each 
sitting  as  possible,  and  that  the  filling  of  the  diflferent  cavities  in  the 
tooth  be  also  proceeded  with  in  like  manner. 

Dr.  Maynard's  method  is  as  follows : — 

He  takes  white  wax,  and  works  it  into  cotton  or  lint  until  it  is  tho- 
roughly mixed  together.  With  this  he  fills  the  cavities  in  the  tooth. 
But,  before  doing  this,  he  exposes  the  pulp  as  much  as  possible,  ap- 
plies the  arsenic,  and  caps  the  orifice  with  a  cup-shaped  plate  of  lead, 
the  convex  side  outward.  While  this  is  carefully  kept  in  place,  he 
fills  the  cavity  with  the  cotton  and  wax,  very  carefully  and  perfectly, 
in  such  a  way  as  not  to  shut  in  and  compress  any  air  which  might 
press  upon  the  pulp.  This  packing,  as  introduced  by  Dr.  Maynard, 
will  keep  the  "  medicine,"  as  he  terms  it,  perfectly  dry  for  twenty-four 
hours,  or  longer. 


288  DENTAL  PATHOLOGY,  THEEAPEUTICS. 

After  removing  this  packing  and  the  preparation,  he  proceeds  to 
remove  the  pulp.  Instead  of  attempting  to  do  this  at  once,  he  begins 
by  cutting  on  every  side  of  the  orifice,  so  much  enlarging  it  as  to  be 
enabled  to  remove  the  pulp  without  pressing  the  contents  of  the  cavity 
upward. 

His  probes  are  objects  of  peculiar  interest,  especially  those  for  extir- 
pating the  pulp.  Some  of  them  are  made  from  the  main-spring  of  a 
watch,  by  filing  or  grinding  them  sufficiently  narrow  to  enter  the- 
smallest  space  which  he  wishes  to  probe.  In  this  way  he  secures  the 
most  perfect  spring  temper,  a  point  not  easily  attained  in  so  frail  an 
instrument  as  a  probe  adapted  to  this  purpose.  These  probes  are 
bearded  by  cutting  them  with  a  sharp  knife — the  beard  pointing  back- 
ward. With  different  sizes  of  these  and  other  probes,  and  by  enlarg- 
ing the  cavity  from  time  to  time,  he  removes  the  pulp  to  the  extremity 
of  the  root. 

The  late  Dr.  Arthur,  in  a  series  of  ably  written  articles,  published 
in  the  American  Journal  of  Dental  Science,  on  the  treatment  of  caries 
of  the  teeth,  complicated  with  disorders  of  the  pulp  and  peridental 
membrane,  recommended  the  use  of  cobalt  for  destroying  the  pulp  as 
preferable  to  any  other  agent  or  means  that  have  been  employed  for 
the  purpose.  But  as  arsenic  is  the  active  principle  of  cobalt,  it  is  to 
this  agent  it  owes  its  efficacy.  It  has  not,  however,  been  found  to  be 
as  effective  as  the  arsenious  acid. 

In  the  destruction  of  the  pulp  of  a  tooth.  Prof  C.  A.  Harris  em- 
ployed both  mechanical  and  chemical  agents.  He  had  been  in  the 
habit,  for  more  than  twenty  years,  of  occasionally  extirpating  the 
pulp  to  the  extremity  of  the  root  by  introducing  a  very  small  untem- 
pered  instrument,  with  a  spear-shaped  point ;  though  not  at  first  with 
the  view  of  afterward  filling  the  pulp  cavity.  He  had  also  used  the 
actual  cautery  and  arsenious  acid.  To  the  last-named  agent,  as  used 
by  most  dentists  for  destroying  the  vitality  of  teeth,  he  was  at  one 
time  strongly  opposed,  and  believed  a  vast  amount  of  injury  is  pro- 
duced by  it ;  but  with  proper  care  and  judicious  after-treatment,  it 
may  be  used  with  safety,  and,  in  most  cases,  with  advantage.  He 
employed  it  for  destroying  the  vitality  of  the  lining  membrane  and 
pulps  of  the  molar  and  bicuspid  teeth,  and  occasionally  applied  it  to 
the  incisors  and  cuspids.  As  a  general  rule,  however,  when  he  wished 
to  destroy  the  pulp  of  one  of  the  last-named  teeth,  he  extirpated  it 
by  thrusting  a  small  instrument  up  the  pulp  cavity  to  the  extremity 
of  the  root.  When  he  used  arsenic,  he  applied  about  the  thirtieth  or 
fortieth  part  of  a  grain,  with  an  equal  quantity  of  morphine;  placing 
it  on  a  small  piece  of  raw  cotton,  moistened  with  creasote  or  spirits  of 
camphor,  and  sealed  up  the  cavity  with  white  or  yellow  wax.     At  the 


SENSITIVENESS   OF   DENTINE.  289 

expiration  of  seven  or  eight  hours  he  removed  the  wax  and  arsenic, 
and  afterward  the  pulp  of  the  tooth.  If  the  portion  in  the  root  was 
still  sensitive,  he  applied  it  a  second  time ;  but  he  seldom  found  it 
necessary  to  do  so.  There  is  comparatively  little  objection  to  the  use 
of  arsenious  acid,  provided  it  is  judiciously  and  carefully  employed, 
and  not  allowed  to  come  in  contact  with  the  gums. 

Such  agents  as  nitric  acid  and  carbolic  acid  are  also  employed  to 
destroy  pulps.  The  method  being  to  first  apply  the  carbolic  acid  to 
the  exposed  surface  of  the  pulp,  and  then  the  nitric  acid  on  a  small 
disk  of  card-board  cut  a  little  larger  than  the  orifice  of  exposure  and 
retained  for  half  a  minute.  After  this  is  removed  a  second  applica- 
tion of  the  carbolic  acid  is  made,  and  the  pulp  removed  from  the 
cavity  by  means  of  a  barbed  broach.  Some  employ  a  fine  splinter  of 
wood  dipped  in  nitric  acid,  which  is  thrust  into  the  previously  obtunded 
pulp.  Repeated  applications  of  carbolic  acid,  chloride  of  zinc,  nitrate 
of  silver  or  caustic  potash  are  also  preferred  by  some  to  arsenious  acid, 
for  devitalizing  agents.  A  piece  of  hard  elastic  wood,  shaped  to  con- 
form to  the  pulp  canal,  and  suddenly  forced  up  on  the  pulp  by  the 
blow  of  a  condensing  hand-mallet,  is  recommended  by  some  as  being 
almost  painless. 


CHAPTER  XI. 

SENSITIVENESS   OF   DENTINE. 

WHILE  inflammation  of  the  soft  tissues  exhibits  such  symptoms 
as  pain,  redness,  heat  and  swelling,  the  dentine  of  a  tooth  in  a 
similar  pathological  condition  does  not  indicate  all  such  manifesta- 
tions ;  for,  owing  to  its  peculiar  structure,  there  is  no  redness,  on 
account  of  a  want  of  red  globules,  nor  swelling,  on  account  of  the 
density.  There  is,  however,  exalted  sensibility,  and  to  such  a  condition 
the  term  inflammation  has  been  applied.  Inflammation  of  the  dentine 
is  due  to  exposure  of  this  structure  consequent  upon  the  breaking  down 
of  the  enamel  or  protective  covering,  and  its  degree  will  depend  upon 
the  organic  structure  of  the  teeth,  susceptibility  to  irritation  and  the 
nature  of  the  irritating  agents.  Teeth  that  are  very  vascular  and 
highly  organized  are  often  extremely  susceptible  to  the  action  of  irri- 
tating substances,  and  such  a  state  of  exalted  sensibility  may  at  times 
be  occasioned  by  disturbance  of  other  and  remote  organs,  such  as  the 
uterus,  for  example. 

The  direct  cause  of  inflammation  of  the  dentine  is  irritation  of  the 

19 


290  DENTAL  PATHOLOGY,  THERAPEUTICS. 

fibrillse  which  occupy  the  dentinal  tubuli,  and  which  ramify  from  the 
pulp  chamber  of  the  tooth  to,  and  sometimes  even  beyond,  the  periph- 
eral surface  of  the  dentine,  and  which  are  conceded  to  be  prolongations 
of  the  dentine  cells,  known  as  odontoblasts,  arranged  in  a  layer  on  the 
outer  surface  of  the  pulp  and  instrumental  in  the  formation  of  the 
dentinal  structure. 

The  greatest  sensitiveness  is  generally  found  where  the  union  of  the 
dentine  with  the  enamel  occurs,  for  the  reason  that  at  this  point  the 
nerve  fibres  terminate,  and  which  accounts  for  the  greater  sensitiveness 
of  dental  caries  in  its  incipient  stage. 

A  tooth  is  sometimes  exceedingly  sensitive  when  the  pulp  is  not 
exposed  ;  but,  in  the  majority  of  cases,  this  need  not  deter  the  operator 
from  removing  the  decayed  part  and  filling  the  cavity,  for  the  inflam- 
mation of  the  dentine  may  be  confined  to  a  thin  lamina  directly 
beneath  the  carious  matter,  and  the  only  inconvenience  it  will  occa- 
sion the  patient  will  be  a  little  suffering  during  the  operation,  and 
slight  momentary  pain  for  a  few  days,  whenever  anything  hot  or  cold 
is  taken  into  the  mouth.  But  when  the  sensibility  is  so  great  that 
the  patient  cannot  bear  the  removal  of  the  diseased  part,  as  occa- 
sionally occurs,  it  may  be  allayed  by  the  application  of  chloride  of 
zinc  to  the  cavity  of  the  tooth,  for  from  three  to  six  minutes.  When 
this  is  done,  care  should  be  taken  to  prevent  it  from  coming  in  contact 
with  any  of  the  soft  parts  of  the  mouth,  on  account  of  its  active 
escharotic  properties. 

For  the  destruction  merely  of  morbid  sensibility  in  the  solid  struc- 
tures of  a  tooth,  chloride  of  zinc,  according  to  the  author's  experience, 
although  somewhat  less  certain  in  its  effects,  is  superior  to  any  prepa- 
ration dependent  for  its  active  properties  upon  the  presence  of  arsenic. 
With  this  agent  it  rarely  happens  that  more  than  five  minutes  are 
required  to  obtain  the  desired  effect.  Although  a  powerful  escharotic, 
it  does  not,  as  all  arsenical  preparations  are  Jiable  to  do,  produce  any 
deleterious  effect  on  the  pulp  of  the  tooth.  It  is  thought,  however,  in 
some  cases  to  modify  the  texture  of  the  dentine ;  and,  in  the  opinion  of 
some  practitioners,  so  much  so  as  to  render  it  more  easily  acted  upon 
by  decaying  agencies.  When  first  applied,  it  excites  a  sensation  of 
heat,  followed  by  burning  pain ;  but  these  soon  subside,  and  on  re- 
moving it  from  the  tooth,  the  parts  of  the  cavity  with  which  it  was 
in  contact  will,  in  a  large  majority  of  the  cases,  be  found  totally 
insensible  to  the  touch  of  an  instrument. 

The  chloride  may  be  applied  directly  to  the  cavity  of  a  sensitive 
tooth,  without  being  combined  with  any  other  substance,  on  a  little  raw 
cotton  or  lint ;  or  it  may  be  made  into  a  paste  by  mixing  it  with  an 
equal  quantity  of  flour,  the  moisture  which  it  absorbs  from  the  atmo- 


SENSITIVENESS   OF   DENTINE.  291 

sphere  being  sufficient  for  the  formation  of  the  paste ;  or  it  may  be 
mixed  with  a  little  pure  anhydrous  sulphate  of  lime,  in  an  impalpable 
powder,  and  then  applied  to  the  tooth.  But  before  this  is  done,  as 
much  of  the  decomposed  dentine  as  possible  should  be  removed,  and 
the  application  should  be  held  firmly  in  contact  with  the  part  of  the 
cavity  on  which  it  is  intended  to  act.  A  single  application  will 
generally  suffice  to  destroy  the  sensibility  to  a  sufficient  depth  as  will 
enable  the  operator  to  remove  any  remaining  portions  of  decayed 
dentine  without  pain ;  but  repeated  applications  are  sometimes  neces- 
sary. 

The  fortieth  or  fiftieth  part  of  a  grain  of  arsenic  is  sometimes 
applied,  and  allowed  to  remain  from  one  to  three  hours ;  but  there 
is  great  danger  of  destroying  the  vitality  of  the  pulp  by  the  use 
of  this  agent,  even  though  it  be  permitted  to  remain  for  only  a  short 
time.  In  employing  it  for  this  purpose,  however,  great  care  is  neces- 
saiy  to  prevent  the  destruction  of  the  vitality  of  the  pulp,  and  the 
injection  of  the  tubuli  of  the  dentine.  This  is  very  liable  to  happen 
when  applied  to  a  tooth  of  a  very  soft  texture,  especially  if  in  the 
mouth  of  a  young  person,  and  when  the  caries  extends  nearly  to  the 
pulp-cavity.  Cobalt  is  said  to  be  less  dangerous  and  equally  efficacious. 
Tannin  or  tannic  acid  in  alcoholic  solution,  or  in  creasote  and  glycerin, 
are  valuable  applications  for  this  pathological  condition  of  the  dentine. 
Nitrate  of  silver,  chromic  aCid,  and  the  terchloride  of  gold  are  also 
used  for  the  same  purpose — the  nitrate  being  applied  in  either  a  solid 
form  or  in  a  concentrated  solution ;  and  while  it  affects  the  dentine  to 
a  greater  depth  than  either  the  tannic  acid  or  chloride  of  zinc,  yet  its 
action,  is  not  so  painful  as  the  latter. 

Creasote  and  carbolic  acid  are  extensively  used  for  this  condition  of 
dentine,  and  are  among  the  safest  of  these  agents. 

Chloroform  applied  to  the  cavity  on  a  small  piece  of  cotton  will  often 
give  a  temporary  insensibility,  and  has  the  merit  of  being  quite  harm- 
less;  which  cannot  be  said  of  chloride  of  zinc,  arsenic,  or  cobalt — the 
first  sometimes  acting  injuriously  upon  the  dentine,  the  two  latter  upon 
the  dental  pulp. 

A  mixture  of  chloroform  and  aconite,  equal  parts,  is  also  recom- 
mended ;  also,  carvacrol,  oil  of  cloves,  oil  of  cedar,  oil  of  eucalyptus, 
glycerine  and  tannin,  creasote  and  tannin,  camphor  and  chloral  solu- 
tion, camphorized  ether,  oxide  of  calcium  (this  latter,  however,  causes 
considerable  pain  when  first  applied),  cai'bouate  of  sodium,  menthol, 
thymol,  the  sesquichloride  of  chromium,  a  mixture  of  equal  parts  of 
tincture  of  aconite  and  a  saturated  solution  of  iodine,  carbonate  of 
potash,  equal  parts  of  sulphate  of  morphine  and  gum  camphor,  ethylate 
of  sodium,  carbonate  of  potash  and  glycerine,  and  the  insertion  of  tem- 


292  DENTAL  PATHOLOGY,  THERAPEUTICS. 

porary  fillings  composed  of  oxychloride  of  zinc  or  oxyphosphate  of 
zinc,  or  Hill's  stopping. 

A  safe  way  of  meeting  the  difficulty  is  to  have  the  excavators  and 
burs  very  sharp  and  well  tempered,  and  to  cut  firmly  and  decidedly 
(for  the  scraping  of  a  dull  instrument  is  quite  as  painful  as  the  cut  of  a 
sharp  one),  making  cuts  "  which  sweep  the  circumference  of  the  cavity," 
or  in  a  direction  from  the  pulp  chamber. 

Friction,  by  means  of  a  burnisher,  is  also  recommended  as  being 
effectual  where  the  position  of  the  sensitive  surface  will  permit  of  its 
use. 

When  painful  escharotics  are  employed,  the  sensitiveness  of  the  den- 
tinal surface  should  first  be  obtunded  by  the  application  of  a  solution 
of  sulphate  of  atropine,  or  other  local  anaesthetic. 

Having  noticed  the  agents  usually  employed  for  destroying  morbid 
sensibility  in  dentine,  we  will  proceed  to  notice  a  few  of  the  non-con- 
ductors of  caloric  that  have  been  used  for  the  accomplishment  of  the 
same  object.  Among  the  substances  which  have  been  employed  for 
this  purpose  are  asbestos,  gutta  percha,  mil's  stopping,  cork,  oiled  silk ; 
also  such  filling  materials  as  the  oxychloride  and  oxyphosphate  of  zinc 
may  prove  serviceable. 

Asbestos,  as  a  non-conductor  of  caloric,  certainly  possesses  every 
desirable  property,  and  is  as  indestructible  in  a  tooth  as  gold.  When 
used  for  this  purpose,  the  purest  variety  should  be  selected.  A  small 
pellet  made  from  the  filaments  of  this  mineral,  placed  in  the  bottom 
of  a  cavity  previously  to  filling,  will  effectually  prevent  irritation  of 
the  pulp  from  impressions  of  heat  and  cold.  The  cavity,  however, 
should  be  first  properly  prepared,  washed  with  tepid  water,  and  made 
jDerfectly  dry.  The  asbestos  may  occupy  from  one-fourth  to  one-sixth 
of  the  depth  of  the  cavity  after  the  filling  has  been  introduced  and 
consolidated. 

A  thin  layer  of  gutta  percha  placed  in  the  bottom  of  the  cavity,  pre- 
viously to  introducing  the  gold,  is  as  effectual  in  preventing  the  trans- 
mission of  impressions  of  heat  and  cold  as  asbestos,  and  can  be  more 
conveniently  applied.  There  is,  however,  a  preparation  of  it,  known 
as  "  Hill's  stopping,"  which  is  better  than  the  simple  article. 

Cork,  though  an  equally  good  non-conductor  of  caloric,  is  thought 
by  some,  as  it  is  more  destructible  than  asbestos  or  gutta  percha,  to  be 
objectionable;  but  cut  off,  as  it  necessarily  would  be  in  the  bottom  of 
the  cavity  beneath  the  filling,  its  liability  to  undergo  any  change  would 
seem  to  be  rendered  wholly  impossible.  It  is  objected  to  its  use,  that 
it  is  of  a  more  porous  nature  than  gutta  percha,  and  cannot  be  adapted 
as  perfectly  to  the  inequalities  of  the  floor  of  the  cavity.  Also  that 
there  is  danger,  in  introducing  the  filling,  of  forcing  some  portions  of 


ALVEOLAR   PERIOSTITIS.  293 

the  gold  through  it,  unless  a  very  thick  piece  be  used.  Oiled  silk  has 
also  been  used  in  some  cases  very  successfully,  but  it  is  not  as  good  a 
non-conductor  as  any  of  the  afore-mentioned  agents. 

The  filling  materials  known  as  oxychloride  of  zinc  and  oxyphosphate 
of  zinc  often  prove  effectual  in  preparing  a  sensitive  cavity  for  a  more 
durable  metallic  filling.  For  the  method  of  applying  these  agents, 
and  also  Hill's  stopping,  the  reader  is  referred  to  the  chaptei-  on 
"  Materials  Employed  for  Filling  Teeth." 

Should  it,  however,  be  necessary  to  fill  the  cavity  with  a  more  per- 
manent material,  such  as  metal,  and  the  inflammation  is  confined  to  a 
portion  of  the  dentine,  this  may  be  protected  by  a  layer  of  the  non- 
conducting material,  and  the  metal  introduced  over  it. 


CHAPTER  XII. 

ALVEOLAR   PERIOSTITIS. 


ALVEOLAR  periostitis,  periodontitis,  dental  periostitis,  perideutitis, 
pericementitis,  as  the  affection  is  variously  named,  denotes  in- 
flammation of  the  investing  membrane  of  the  roots  of  the  teeth,  a 
tissue  highly  vascular  and  very  susceptible  to  inflammatory  conditions, 
and  may,  in  a  great  majority  of  cases,  be  regarded  as  a  premonitory 
stage  of  alveolar  abscess,  as  it  rarely  occurs  before  the  pulp  has  been 
deprived  of  its  vitality. 

Inflammation  of  the  periosteum  of  a  tooth  may  be  acute  or  chronic, 
the  acute  form  being  generally  due  to  direct  local  irritation,  and  the 
chronic  form  to  systemic  influences.  Each  variety  is  modified  in  its 
character  by  the  state  of  the  constitutional  health,  and  by  the  causes 
concerned  in  its  production.  The  premonitory  symptoms  of  the  acute 
variety  are  a  slight  sensation  of  uneasiness  and  tension,  a  feeling  of 
fullness  about  the  affected  part,  and  a  desire  to  press  the  teeth  together. 
Pressure  appears  to  afford  temporary  relief,  but  the  uneasy  feeling 
returns  on  the  pressure  being  withdrawn. 

These  symptoms  are  soon  followed  by  a  dull,  heavy  and  continuous 
pain,  and  the  affected  tooth  appears  to  be  longer  than  the  adjoining 
ones,  and  is  really  so,  owing  to  the  increased  thickness  of  the  investing 
membrane  of  the  root.  Occlusion  of  the  teeth  gives  rise  to  severe  j^ain, 
and  there  is  an  inclination  to  keep  the  jaws  apart.  The  appearance  of 
the  gums  at  this  stage  of  the  affection  also  indicates  the  existence  of 
disease  in  the  investing  membrane ;  they  become  very  tender   and 


294 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


Fig.  92. 


swollen,  and  change  from  a  pale  rose  color  to  a  deep  red  or  purple 
opposite  the  root  of  the  affected  tooth. 

At  first  the  inflammation  is  confined  to  the  free  margins,  but  soon  it 
becomes  more  general,  until  the  whole  of  the  gum  about  the  root  of 
the  tooth  is  involved.  Although  the  pain  increases  in  severity,  it  yet 
preserves  the  same  character,  and  even  when  not  continuous,  it  seldom 
ceases  for  any  great  length  of  time.  At  length  suppuration  occurs, 
and  we  have  the  condition  known  as  alveolar  abscess  ;  this  process 
sometimes  extending  to  nearly  every  part  of  the  periosteum,  causing 
the  entire  death  of  the  tooth,  and  often  followed  by  erosion  of  the  root 
and  necrosis  of  the  alveolus.  When  favored  by  a  cachectic  habit  of 
body,  it  often  extends  to  the  periosteum  of  the  jaw,  followed  by  sup- 
puration and  necrosis.  The  following  case  will  give  some  idea  of  the 
severity  it  occasionally  assumes  : — 

In  1840,  a  poor  girl,  aged  fourteen,  was  brought  to  the  author. 
About  three  months  before  she  had  been  taken  to  a  barber  tooth - 
drawer  for  the  purpose  of  having  the  first  left  inferior  molar  extracted. 
The  crown  was  broken  off",  the  roots  left  in  the  socket.  Inflammation 
supervened.  This  soon  extended  to  the  periosteum  of  the  entire  bone 
from  the  second  bicuspid  to  the  coronoid  process ;  as  it  was  permitted 

to  run  its  course  uninterruptedly, 

-        it  terminated  in  necrosis  and  ex- 

/  p-}^^  foliation  of  all  this  portion  of  the 

^^^  bone  (Fig.  92),  the  anterior  ex- 

r^'W^^^^^^  tremity  of  which,  when  first  seen 

-^^^  f^':':^^^^^^'  by  the  author,  had  passed  through 

the  integuments  of  the  lower  part 
of  the  face,  and  protruded  ex- 
ternally. A  few  days  after  it 
was  removed  without  difiiculty. 
Acute  inflammation  of  the  periosteum  having  terminated  in  suppu- 
ration, sometimes,  instead  of  subsiding  altogether,  degenerates  into  a 
chronic  form,  and  when  favored  by  some  constitutional  vice,  as  the 
scorbutic,  venereal,  or  scrofulous,  it  often  gives  rise  to  the  destruction 
of  the  socket  and  loss  of  the  tooth. 

Chronic  inflammation  of  the  dental  periosteum  is  not  always  pre- 
ceded by  the  active  form  of  the  disease,  but  may  assume  this  form  at 
the  commencement.  In  this  case  it  is  complicated  with  tumefaction 
of  the  gums,  and  discharge  of  puriform  matter  from  between  their 
edges  and  the  necks  of  the  teeth. 

After  the  loss  of  vitality  in  the  pulp  of  a  tooth,  the  periosteum  is 
vei-y  susceptible  to  inflammation,  owing  to  the  irritation  to  which  it  is 
subjected,  and  also  to  the  weakened  condition  of  this  membrane,  and 


ALVEOLAR   PERIOSTITIS.  295 

its  increased  function  in  supplying  the  cementum  and  dentine  with 
nourishment. 

CAUSES. 

Alveolar  periostitis,  in  most  instances,  is  the  result  of  inflammation 
of  the  pulp  of  a  tooth,  either  from  direct  exposure  or  the  presence  of 
an  irritating  substance,  such  as  the  remains  of  a  dead  or  decomposing 
pulp,  salivary  calculus,  the  free  use  of  arsenious  acid,  the  injudicious 
use  of  agents  employed  for  obtunding  the  sensitiveness  of  dentine,  the 
action  of  mercurial  remedies,  etc.  It  may  also  result  from  the  loss  of 
an  antagonizing  tooth,  violence,  proximity  of  a  metallic  filling  to  the 
pulp,  overhanging  portions  of  a  filling,  and  the  presence  of  caries  be- 
yond the  margin  of  the  gum.  Besides  the  local  causes  enumerated, 
there  are  also  constitutional  causes,  such  as  a  syphilitic  taint  through 
an  infiltration  of  lymph  and  serum  into  the  periosteum,  or  between  it 
and  the  I'oot  of  the  tooth  or  alveolar  walls  of  the  socket ;  also  rheu- 
matism, especially  in  those  who  have  been  subjected  to  an  excess  of 
mercury,  and  scrofula,  which  produces  a  form  of  periostitis  common  to 
children.  This  affection  may  also  extend  from  the  periosteum  of  one 
tooth  to  that  of  adjoining  teeth. 

TREATMENT. 

The  treatment  of  alveolar  periostitis  will  depend  upon  the  causes 
producing  and  influencing  the  disease,  and  the  condition  of  the  gen- 
eral system.  The  first  thing  to  be  attended  to  is  the  removal  of  all 
irritants,  after  which  the  congestion  of  the  affected  part  may  be  re- 
lieved by  the  use  of  such  agents  as  produce  counter-irritation,  or  by 
depletion. 

When  the' pulp  of  the  tooth  is  inflamed  it  should  receive  immediate 
attention,  and  if  the  pulp  is  dead,  all  the  debris  should  be  removed 
from  its  canal  by  means  of  nerve  instruments,  and  syringing  with 
tepid  water.  All  deposits  of  calculus  should  be  removed  from  the 
teeth,  and  also  all  dead  teeth  and  roots  which  are  useless  and  cause 
irritation.  To  produce  counter-irritation,  the  gums  may  be  scarified, 
or  such  agents  be  applied  as  iodine  and  creasote,  tincture  of  capsicum, 
and  tincture  of  iodine.  An  excellent  application  is  composed  of  equal 
parts  of  the  officinal  tincture  of  iodine  and  tincture  of  aconite  root 
applied  to  the  gum  two  or  three  times  daily,  in  the  acute  form  of  the 
affection.  Previous  to  the  application,  the  gum  should  be  dried,  and 
afterwards  the  cheek  kept  from  coming  in  contact  with  it  until  a  me- 
tallic pellicle  is  formed.  Cantharidal  collodion  is  also  an  excellent 
counter-irritant,  and  is  applied  to  the  gum,  after  the  surface  is  dried 
with  a  napkin,  by  means  of  a  camel's-hair  brush,  taking  care  to  pro- 
tect the  lip,  and  to  prevent  moisture  from  interfering  before  the  ether 


296  DENTAL  PATHOLOGY,  THERAPEUTICS. 

in  the  preparation  evaporates  and  an  artificial  cuticle  is  formed. 
Within  a  few  hours  blistering  results,  and  the  periostitis  is  effectually 
relieved.  Another  method  of  producing  counter-irritation  is  to  make 
a  deep  incision  in  the  gum  over  the  affected  root,  and  to  introduce  into 
this  a  small  pellet  of  cotton  or  lint  saturated  with  creasote,  or  carbolic 
acid,  which  is  retained  for  from  one  to  five  days,  the  time  depending 
upon  the  persistence  of  the  inflammation,  taking  the  precaution  to 
change  the  dressing  every  day.  The  application  of  a  solution  com- 
posed of  equal  parts  of  tincture  of  aconite,  tincture  of  opium,  and 
chloroform,  is  often  very  serviceable ;  also  a  small  linen  bag  containing 
capsicum,  one  side  of  the  bag  being  covered  with  leather,  to  protect  the 
cheek.  Lead-water,  in  the  proportion  of  a  fluidounce  to  two  fluid- 
drachms  of  laudanum,  applied  in  the  same  manner  as  the  agent  before 
named,  has  also  been  successfully  used.  Depletion  may  be  accom- 
plished by  means  of  the  gum  lancet,  or  by  the  use  of  leeches  or  cups. 

Hypodermic  injections  of  morphine  have  also  been  resorted  to  for  the 
relief  of  the  intense  pain  of  this  affection,  such  as  a  solution  of  mor- 
phine or  tincture  of  opium,  some  ten  to  twenty  drops  being  injected 
with  a  suitable  syringe  beneath  the  mucous  membrane ;  also,  with  good 
effect,  the  application  of  rhigolene  or  ether  spray  until  the  gum  about 
the  affected  tooth  is  blanched.  As  a  topical  application,  rhigolene  has 
been  recommended,  applied  to  the  gum  on  a  pellet  of  cotton  after  free 
scarification. 

Constitutional  treatment  is  also  serviceable,  such  as  the  administra- 
tion of  saline  cathartics.  Bromide  of  potassium  in  a  dose  of  twenty- 
five  grains,  or  the  same  quantity  of  the  bromide  combined  with  five 
drops  of  the  tincture  of  veratrum  viride,  and  repeated  every  four 
hours,  will  often  prove  serviceable  in  incipient  alveolar  periostitis.  A 
preparation  known  as  mercurius  vivus,  the  third  decimal  trituration, 
given  in  small  doses  two  or  three  times  a  day,  has  been  recommended 
by  Prof.  Chase,  and  used  successfully  by  others  in  relieving  acute  peri- 
ostitis. During  the  treatment,  a  cap  of  gutta-percha,  moulded  to  the 
crowns  of  one  or  two  teeth  on  the  opposite  side  of  the  jaw,  will  protect 
the  affected  tooth  from  any  irritation  which  may  be  caused  by  the  oc- 
clusion of  the  opposing  ones,  and  thus  facilitate  the  restoration.  For 
the  treatment  of  the  chronic  variety  of  alveolar  periostitis,  the  reader 
is  referred  to  "Chronic  Inflammation  and  Tumefaction  of  the  Gums." 


ALVEOLAR   ABSCESS.  297 

CHAPTER  XIIL 

ALVEOLAR    ABSCESS. 

AN  alveolar  abscess  is  a  collection  of  pus  in  a  sac  attached  to  and 
closely  embracing  the  root  of  a  tooth.  The  periosteum  of  a  tooth 
having  become  the  seat  of  acute  inflammation,  plastic  lymph  is  effused  at 
the  extremity  of  the  root.  This  is  condensed  into  a  sac  or  cyst,  which 
closely  embraces  the  root  near  its  apex,  the  walls  of  lymph  become 
vascular,  and  perform  the  functions  of  secretion  and  absorption,  and  as 
suppuration  takes  place,  pus  is  formed  in  the  centre  of  the  sac.  The 
inflammation,  in  the  meantime,  having  efxtended  to  the  gums  and 
neighboring  parts,  they  swell  and  become  painful,  and  as  the  pus  accu- 
mulates in  the  sac,  it  distends  and  presses  upon  the  surrounding  walls 
of  the  alveolus,  which,  by  a  sort  of  chemico-vital  process,  are  gradually 
broken  down.  By  absorption,  through  pressure,  an  opening  is  ulti- 
mately made  through  one  side  of  the  alveolar  cavity,  when  the  pus, 
coming  in  contact  with  the  investing  soft  structures,  presses  upon  them 
and  causes  their  absorption  also.  Thus  an  outlet  is  effected  for  the 
escape  of  the  accumulated  matter. 

The  pus  of  an  alveolar  abscess,  in  the  case  of  young  persons,  usually 
finds  an  exit  through  the  root  canal  of  the  tooth,  especially  when  the 
abscess  is  formed  upon  the  apex  of  the  root,  owing  to  the  large  size  of 
the  foramen  of  a  tooth  with  a  single  root.  At  other  times  the  pus  may 
make  its  way  to  the  surface  between  the  root  and  the  wall  of  the  cavity. 
In  adult  persons  the  escape  of  the  pus  generally  takes  place  through 
the  alveolar  wall  and  the  soft  tissues  opposite  the  root  of  the  affected 
tooth. 

The  secretion  of  an  alveolar  abscess,  especially  when  an  inferior  molar 
is  affected,  may  find  its  way  to  the  surface  of  the  cheek  or  neck,  and 
considerable  deformity  be  caused  from  the  cicatrix  resulting.  In  some 
cases  the  sinus  of  an  abscess  may  invade  the  duct  of  a  salivary  gland, 
and  necessitate  the  operation  for  salivary  fistula,  before  a  cure  can  be 
effected  ;  but  the  secretion  may  escape  from  a  more  remote  point.  It 
may  make  for  itself  an  opening  through  the  cheek  or  through  the  base 
of  the  lower  jaw,  and  be  discharged  externally  ;  or  it  may  pass  up  into 
the  maxillary  sinus,  or  through  the  nasal  plates  of  the  superior  maxilla, 
or  form  a  passage  between  the  two  plates  of  the  bone,  and  escape  from 
the  centre  of  the  roof  of  the  mouth. 

The  formation  of  abscess  in  the  alveolus  of  an  inferior  dens  sapientise 
is  sometimes  attended  with  inflammation  and  swelling  of  the  tonsils  and 


298 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


of  the  muscles  of  the  cheek  and  neck.     The  author  has  known  trismus 
to  result  from  this  cause. 

The  pain  attending  the  formation  of  alveolar  abscess  is  deep-seated, 
throbbing,  and  often  so  excruciating  as  to  be  almost  insupportable. 
But  as  soon  as  suppuration  takes  place,  it  loses  its  severity,  and  with 
the  escape  of  the  pus  nearly  or"  altogether  ceases ;  but  the  tooth,  from 
the  thickened  condition  of  the  alveolo-dental  periosteum,  particularly 
at  the  apex  of  the  root,  often  remains  sore  and  sensitive  to  the  touch 
for  several  days.  The  energies  of  the  disease,  however,  having  been 
expended,  the  secretion  of  the  pus,  in  the  majority  of  cases  wholly 
ceases,  and  the  opening  in  the  gums  closes.  From  the  increased  sus- 
ceptibility in  the  alveolo-dental  periosteum  to  morbid  impressions, 
occasioned  by  the  presence  of  a  tooth  deprived  of  a  large  portion  of  its 
vitality,  a  recurrence  of  the  inflammation  is  liable  to  take  place,  when 
pus  will  be  again  formed  and  the  passage  for  its  escape  re-established. 
But  the  pain  attending  any  subsequent  attack  is  seldom  so  severe  as  in 
the  first  instance. 

There  are  some  cases,  however,  in  which  the  inflammation,  instead 
of  subsiding  altogether,  degenerates  into  a  chronic  form.  In  this  case, 
the  sac  at  the  extremity  of  the  root  continues  to  secrete  pus,  though  the 
quantity  is  usually  small,  and  the  opening  in  the  gums  remains  unclosed. 
Persons  of  a  scrofulous  diathesis  are  very  liable  to  this  affection, 
which,  in  these  cases,  very  soon  assumes  a  chronic  form. 

In  the  extraction  of  a  tooth  which  has  given  rise  to  the  formation  of 
abscess,  the  sac  is  often  brought  aw^ay  with  it.  Two  teeth  in  which  this 
had  happened,  taken  from  the  upper  jaw — one  a 
cuspid,  and  the  other  a  first  molar — are  repre- 
sented in  the  accompanying  cuts  (Figs.  93  and 
94).  In  the  case  of  the  molar,  the  sac  is  attached 
to  the  palatine  root.  Both  of  these  teeth  were 
extracted  previously  to  the  formation  of  an  ex- 
ternal opening  for  the  escape  of  the  matter. 

Although  in  the  majority  of  cases  the  sac  is 
attached  to  the  apex  of  the  root,  yet  it  is  not 
unusual  for  the  point  of  attachment  to  be  on  the 
side  of  the  root,  as  in  the  case  of  the  superior  front  teeth,  and  bicuspids, 
or  in  the  bifurcation  of  the  roots,  in  the  case  of  the  molars,  for  example. 
When  the  sac  is  situated  upon  the  side  of  the  root  of  a  superior  front 
tooth,  it  is  generally  upon  the  labial  surface,  and  when  it  is  situated 
at  the  apex  of  the  root  of  a  molar  tooth,  the  palatine  root  is  the  one 
generally  affected.  The  temporary  teeth  are  much  more  liable  to  this 
disease  than  the  permanent  teeth,  and  the  superior  incisors  more 
susceptible  than  the  inferior  teeth  of  the  same  class. 


Fig.  94. 


ALVEOLAR  ABSCESS.  299 

But  the  treatment  of  inferior  teeth  affected  with  abscess,  especially 
the  bicuspids  and  molars,  is  often  more  difficult  than  that  of  the  su- 
jDerior,  on  account  of  the  gravitation  of  the  pus,  and  the  impossibility 
in  many  cases  of  making  an  opening  through  the  alveolar  process  so 
low  as  the  extremity  of  the  root,  owing  to  the  muscular  attachment 
being  so  high  on  the  ridge. 

The  character  of  the  seci'etion  differs  considerably  in  different  cases  ; 
instead  of  the  yellowish-white  appearance  that  pure  or  laudable  pus 
presents,  and  which  may  be  present  in  some  cases  of  alveolar  abscess 
in  good  constitutions,  a  highly  vitiated,  acrid  fluid,  with  either  a 
diminished  supply  of  pus  corpuscles  or  an  entire  absence  of  such  cor- 
puscles, usually  distinguishes  the  secretion,  which  sometimes  becomes 
very  irritating  in  its  effect  upon  living  tissue.  The  systemic  condition 
of  the  patient  modifies  the  character  of  the  secretion,  as  also  does  the 
nature  of  the  local  irritants. 

The  time  required  for  the  formation  of  alveolar  abscess  varies  from 
three  to  ten  or  fifteen  days,  according  to  the  violence  of  the  inflamma- 
tion. But  a  collection  of  pus  may  be  detected  by  fluctuation  under  the 
finger,  if  applied  to  the  tumefied  gum  one  or  two  days  before  an 
external  opening  is  spontaneously  formed  for  its  escape. 

The  size  of  the  cavity  formed  by  an  alveolar  abscess  depends  upon 
the  severity  of  the  disease,  and  the  susceptibility  of  the  parts  involved. 
In  some  cases  it  is  quite  small  and  confined  to  the  point  of  irritation, 
w'hile  in  others  it  may  be  very  extensive.  Very  severe  pain  accom- 
panies this  affection  when  the  abscess  is  rapidly  formed,  owing  to  the 
distention  occasioned,  and  the  inability  of  the  secreting  pus  to  escape. 
As  soon  as  an  opening  is  effected,  however,  the  tension  is  relieved  and 
the  pain  subsides.  A  great  susceptibility  to  alveolar  abscess  exists  in 
case  of  an  inflammatory  diathesis,  and  after  a  time  it  may  assume  a 
chronic  character,  when  the  secretion  and  discharge  of  the  pus  is  con- 
tinuous. Although  the  pain  may  not  be  more  than  a  slight  uneasiness, 
the  acute  form  is  productive  of  intense  pain.  There  is  also  a  difference 
in  the  extent  of  the  iuflammation  affecting  neighboring  tissues,  depend- 
ing upon  the  activity  of  the  irritants  present,  as  in  some  cases  of 
alveolar  abscess  the  inflammation  of  adjacent  parts  may  be  very 
limited,  while  in  others  it  may  be  very  extensive. 

The  inflammation  and  pain  attending  the  formation  of  abscess  in  the 
alveolar  cavity  of  a  tooth  often  give  rise  to  general  febrile  symptoms, 
headache  and  constipation  of  the  bowels.  In  the  acute  form  of  this 
disease,  the  pain  is  intense,  w^hile  in  the  chronic  form,  where  the  pus 
is  constantly  secreting  and  discharging,  the  sensation  experienced  is 
soreness  and  an  uneasy  feeling,  with  slight  pain  upon  a  change  of 
temperature. 


300  DENTAL   PATHOLOGY,  THERAPEUTICS. 

CAUSES. 

The  immediate  cause  of  alveolar  abscess  is  inflammation  of  the 
alveolo-dental  periosteum,  and  this  may  arise  from  inflammation  and 
suppuration  of  the  lining  membrane  and  pulp ;  or  from  an  accumula- 
tion of  purulent  matter  at  the  extremity  of  the  root,  the  egress  of  which, 
through  the  natural  opening,  has  been  prevented ;  for  example,  where 
the  cavity  in  the  crown  of  a  tooth  has  been  filled  and  the  decomposed 
pulp  allowed  to  remain  in  the  root  canal.  It  may  also  be  produced 
by  mechanical  violence,  the  irritation  of  a  dead  tooth,  or  by  a  drill 
accidentally  passing  from  the  canal  through  the  side  of  the  root  into 
the  periosteum,  or  by  the  presence  of  a  portion  of  a  gold  filling  forced 
through  the  root  of  a  tooth. 

TREATMENT. 

The  treatment  of  alveolar  abscess  should  be  preventive  rather  than 
curative,  for  it  rarely  happens,  after  it  has  occurred,  that  the  integrity 
of  the  parts  is  so  perfectly  restored  as  to  prevent  a  recurrence  of  the 
afiection.  Although  the  secretion  of  pus  may  cease  for  a  time,  and 
the  opening  in  the  gums  become  obliterated,  the  tooth,  being  deprived 
of  a  large  portion  of  its  vitality,  is  liable,  whenever  the  excitability  of 
the  alveolo-dental  periosteum  is  increased  by  any  derangement  of  the 
general  system,  to  give  rise  to  a  recurrence  of  the  disease.  Especially 
is  this  the  case  when  the  disease  has  assumed  the  chronic  form.  The 
formation  of  an  abscess,  therefore,  should,  if  possible,  be  prevented  by 
the  use  of  such  means  as  are  referred  to  in  the  treatment  of  "Alveolar 
Periostitis,"  a  common  termination  of  this  disease  being  alveolar 
abscess.  But  should  these  means  fail  to  prevent  the  formation  of  pus, 
we  then  have  to  resort  to  either  therapeutic  or  surgical  treatment. 

An  alveolar  abscess  of  recent  origin  will  yield  more  readily  to  treat- 
ment than  one  of  long  continuance,,  and  the  chronic  form  is  much 
more  difiicult  to  arrest,  especially  after  the  adjacent  parts  have  become 
involved,  than  the  acute  form. 

When  constitutional  derangement  is  present,  general  treatment,  such 
as  the  particular  condition  indicates,  must  be  resorted  to.  The  local 
or  surgical  treatment  consists  in  breaking  up  the  sac  of  the  abscess, 
and  ready  access  must  be  had  to  the  point  of  accumulation  in  order 
to  successfully  accomplish  such  a  result. 

A  sharp-pointed  bistoury  or  small  trephine,  may  be  employed  to 
enlarge  the  fistulous  canal,  when  the  pus  has  made  an  opening  through 
the  process  and  gum  to  the  surface  opposite  the  root  of  the  tooth,  and 
the  sac  broken  up  by  means  of  nerve  instruments,  its  remains  being 
thrown  off,  and  healthy  granulations  developing  without  further  treat- 
ment.   In  many  cases,  however,  therapeutic  treatment  must  follow  the 


ALVEOLAR  ABSCESS. 


301 


surgical,  befoi'e  a  perfect  cure  is  accomplished.  The  therapeutic  treat- 
ment consists  in  first  removing  all  irritating  substances  from  the  pulp 
canal,,  which  should  be  freely  opened  to  the  apex  of  the  root,  and  the 
application  of  disinfectant  and  antiseptic  remedies.  For  cleansing  the 
root,  chloride  of  sodium  injected  into  the  canal  answers  a  good  pur- 


FlG. 


Fig.  96. 


pose,  to  be  followed  by  such  agents  as  will  cause  the  absorption  or 
destruction  of  the  sac  containing  the  pus,  such  as  creasote,  carbolic 
acid,  salicylic  acid  (applied  in  the  solid  form),  nitrate  of  silver,  iodine, 
etc.  The  contents  of  the  abscess,  however,  should  first  be  discharged  by 
making  an  oj)ening  in  the  tumefied  gum  with  a  sharp  lancet,  provided 


302  DENTAL  PATHOLOGY,  THERAPEUTICS. 

the  disease  has  been  allowed  to  progress  to  such  a  degree  as  to  render 
this  operation  necessary.  If  no  opening  has  been  formed  through  the 
alveolar  process,  the  decay  in  the  crown  cavity  should  be  removed,  and 
the  orifice  of  the  pulp  canal  be  so  enlarged  as  to  admit  a  nerve  instru- 
ment or  small  broach,  by  means  of  which  it  can  be  cleaned  out,  and 
thus  allow  the  matter  to  escape  through  the  tooth.  Tepid  water  should 
then  be  injected  into  the  pulp  canal  by  means  of  a  small  syringe  until 
all  decomposed  matter  is  removed,  when  one  of  the  remedial  agents 
mentioned  above  may  be  substituted  for  the  tepid  water,  or  applied  on 
a  strand  of  floss  silk,  which  is  carried  to  the  apex  of  the  root  by  means 
of  a  nerve  instrument  or  broach.  At  the  end  of  twenty-four  or  forty- 
eight  hours,  according  to  the  character  of  the  symptoms,  this  treatment 
is  repeated,  the  crown  cavity  during  the  interval  being  filled  with 
cotton.  A  combination  of  several  of  the  remedial  agents  is  serviceable 
in  obstinate  cases,  such  as  creasote  and  tincture  of  iodine,  carbolic  acid 
and  tincture  of  iodine,  or  creasote  and  tannin  in  alcohol,  which  can 
be  applied  daily  on  floss  silk,  followed  by  clean  silk  introduced  daily 
for  two  or  three  days,  until  the  discharge  ceases. 

Figs.  95  and  96  represent  Dr.  J.  N.  Farrar's  alveolar  abscess 
syringe,  for  injecting  iodine,  carbolic  acid,  etc.,  and  also  an  ordinary 
hard  rubber  syringe  for  the  same  purpose. 

The  following  solution  of  Dr.  Percy  Boulton  possesses  therapeutic 
virtues  of  superior  efiiciency,  especially  after  creasote,  or  carbolic  acid, 
or  nitrate  of  silver  have  been  used  to  stimulate  the  secreting  surfaces 
to  a  healthy  action  : — 

R.     Tr.  iodine  comp y\xiv 

Acid  carbolic  cryst.  (fusa) ttlvj 

Glycerinae S'^iij 

Aq.  destillat 5v.  M. 

This  solution  possesses  antiseptic  and  stimulant  properties. 

Where  a  fistulous  opening  exists  through  the  wall  of  the  alveolar  cav- 
ity and  gum,  this  opening  should  be  enlarged,  and  the  remedial  agents, 
after  the  accumulated  pus  has  escaped,  be  thus  applied  directly  to  the 
seat  of  the  disease.  In  the  chronic  form  of  this  disease,  accompanied  with 
a  fistulous  opening  through  the  alveolar  process  and  gum,  some  opera- 
tors are  in  the  habit  of  carefully  cleaning  out,  preparing  and  filling 
the  pulp  canal  to  the  extremity  of  the  root,  and  after  this  treating  the 
abscess  through  the  fistulous  opening  (which  is  enlarged  for  the  pur- 
pose), either  by  the  application  of  therapeutic  agents  or  by  what  is 
designated  the  surgical  treatment. 

This  surgical  treatment  consists  in  making  an  opening,  or  enlarging 
the  fistulous  one,  through  the  alveolus,  opposite  the  extremity  of  the 


ALVEOLAR  ABSCESS.  303 

affected  root,  by  means  of  a  small  trephine,  drill,  or  chisel,  first  making 
a  vertical  incision  in  the  gum  with  the  lancet,  and  thus  gaining  access 
to  the  seat  of  the  disease.  The  attachment  of  the  sac  to  the  root  is 
then  broken  up  by  means  of  a  delicate  instrument  Avhich  permits  of 
being  passed  about  the  extremity  of  the  root,  and  the  wound  in  the 
gum  kept  open  for  a  few  days  by  inserting  a  tent,  in  order  that  the 
remains  of  the  sac  may  escape,  and  such  agents  as  tannin  and  glycerine, 
carbolic  acid  and  glycerine,  etc.,  may  be  applied.  It  rarely  happens 
that  this  surgical  treatment  can  be  made  through  the  pulp  canal  of  the 
root  and  without  an  opening  in  the  alveolar  process.  During  treat- 
ment, to  prevent  the  occlusion  of  the  teeth,  where  this  may  be  neces- 
sary, a  cap  of  gutta-percha  can  be  moulded  over  the  adjoining  teeth 
by  first  softening  this  material  in  warm  water.  The  excision  of  the 
apices  of  the  roots  of  teeth,  by  means  of  a  small  trephine,  and  thus 
bringing  away  the  sacs  also,  has  been  recommended  as  successful  sur- 
gical treatment  of  alveolar  abscess. 

Dilute  aromatic  sulphuric  acid  is  a  very  reliable  application,  either 
alone  or  combined  with  a  small  quantity  of  tincture  of  capsicum,  in 
chronic  cases  of  alveolar  abscess  of  long  standing  associated  with  a 
necrosed  condition  of  the  margins  of  the  processes. 

Replantation  is  also  resorted  to,  and  in  many  cases  may  prove  effi- 
cient, if  care  is  exercised  to  remove  all  coagulated  lymph  and  diseased 
membrane,  and  also  to  fill  the  canal  permanently  before  returning  the 
tooth  to  its  cavity.  Under  favorable  circumstances  a  tooth  thus  treated 
may  become  firmly  attached  within  a  few  days. 

When  escharotic  agents  are  injected  into  the  pulp  cavity  and  through 
the  fistulous  opening  in  the  process  and  gum,  their  contact  with  the 
mucous  membrane  may  be  prevented  by  the  introduction  of  a  Hill's 
stopping  filling  in  the  crown  cavity,  in  the  centre  of  which  an  opening 
is  made  to  admit  closely  the  point  of  the  syringe,  while  at  the  same 
time  the  parts  about  the  fistulous  opening  are  protected  by  bibulous 
paper,  cotton,  and  napkins.  When  there  is  a  tendency  of  the  accumu- 
lated pus  in  the  sac  of  an  abscess  upon  one  of  the  inferior  teeth  to 
discharge  through  an  external  opening  in  the  cheek,  or  beneath  the 
jaw,  this  result  may  be  prevented  by  a  free  incision  in  the  gum  opjDO- 
site  the  root  of  the  afiected  tooth;  should  the  discharge,  however, 
through  an  external  opening  be  inevitable,  the  immediate  extraction  of 
the  tooth  is  necessary. 

The  application  of  fomentations  and  emollient  poultices  exter- 
nally are  rarely  productive  of  any  advantage,  and  may  do  harm  by 
promoting  the  discharge  of  matter  through  the  cheek  or  lower  part 
of  the  face.  When  this  occurs,  a  depression,  with  puckering  of 
the   skin,   is   apt   to  remain   after   the   escape   of  pus   through   the 


304  DENTAL   PATHOLOGY,  THERAPEUTICS. 

opening  ceases  and  the  orifice  has  closed,  causing  disfiguration  of  the 
face. 

It  rarely  happens,  however,  that  anything  more  is  necessary  for  the 
cure  of  the  external  opening  than  the  extraction  of  the  tooth  which 
has  given  rise  to  the  formation  of  the  abscess.  The  author  has  been 
consulted  in  many  cases,  and  has  never  found  it  necessary  to  resort  to 
other  means  ;  but  should  the  external  opening  remain,  the  wall  of  the 
tube  and  depression  may  be  removed  in  the  manner  just  described. 

The  formation  of  an  abscess  in  the  alveolus  of  a  lower  wisdom  tooth 
is  sometimes  productive  of  very  serious  and  even  alarming  consequences. 
The  following  is  one  of  several  similar  cases  which  have  fallen  under 
the  observation  of  the  author : — 

In  1832,  he  was  sent  for  in  great  haste  to  visit  a  physician  who 
resided  thirty  miles  in  the  country.  He  had  been  attacked  two  weeks 
before  with  severe  pain  in  the  left  dens  sapientise  of  the  lower  jaw. 
At  the  expiration  of  three  or  four  days,  a  physician  was  called  in, 
who  made  several  unsuccessful  attempts  to  extract  the  tooth. 

The  inflammation  now  extended  rapidly  to  the  fauces,  tonsils,  and 
muscles  of  the  jaw  and  face.  Obstructed  deglutition  and  a  constant 
fever  supervened,  upon  which  repeated  blood-lettings,  cathartics,  and 
fomentations  applied  to  the  face  had  little  effect.  His  respiration  was 
difficult,  and  the  muscles  of  his  jaws  soon  became  so  rigid  and  firmly 
contracted  that  his  mouth  could  not  be  opened. 

This  was  the  condition  of  the  patient  when  the  author  first  saw 
him,  which  was  the  morning  of  the  day  following  the  one  on  which  he 
was  sent  for.  In  addition  to  the  treatment  which  had  previously  been 
pursued,  an  injection  with  two  grains  of  tartar  emetic  was  administered. 
About  seven  o'clock  in  the  evening  the  fever  was  succeeded  by  alter- 
nate paroxysms  of  cold  and  heat.  An  effort  was  now  made  to  force 
open  his  mouth  with  a  wooden  wedge.  This  was  partially  successful, 
but  his  teeth  could  not  be  forced  asunder  sufficiently  to  admit  of  the 
introduction  of  the  smallest-sized  tooth -forceps.  But  while  his  jaws 
were  thus  partially  separated,  he  attempted  to  swallow  some  warm  tea ; 
in  the  effort  an  abscess  burst  and  discharged  nearly  a  tablespoonful  of 
pus  from  his  mouth,  and  it  was  supposed  that  double  that  quantity 
passed  down  into  his  stomach.  This  gave  immediate  relief,  but  it  was 
not  until  about  three  o'clock  in  the  afternoon  of  the  next  day  that  his 
jaws  could  be  forced  apart  sufficiently  to  permit  the  extraction  of 
the  tooth  which  had  caused  the  trouble.  To  the  roots  of  this,  which 
were  united,  there  was  attached  a  sac,  about  the  size  of  a  large  pea, 
filled  with  pus.  The  patient  recovered  rapidly,  and  in  a  few  days  was 
quite  well. , 

The  following  is  the  most  singular  case  of  alveolar  abscess  which 


ALVEOLAR  ABSCESS.  305 

has  ever  fallen  under  the  observation  of  the  writer.  The  subject  was 
a  lady  about  thirty  years  of  age.  She  had  been  troubled  with  a  drip- 
ping of  pus  from  behind  the  curtain  of  the  palate  for  about  twelve 
mouths,  and  becoming  somewhat  alarmed  at  its  continuance,  she  called 
the  attention  of  her  family  physician,  Prof.  Thomas  E.  Bond,  to  it, 
who  carefully  examined  the  case,  and  endeavored  to  ascertain  the  place 
from  whence  the  matter  came.  He  soon  satisfied  himself  that  it  was 
from  the  socket  of  a  diseased  tooth.  Upon  passing  his  finger  around  on 
the  gums  covering  the  superior  alveolar  border,  he  discovered  a  protu- 
berance over  the  root  of  each  upper  central  incisor,  nearly  as  large  as  a 
hazel-nut.  This  tended  to  confirm  the  opinion  which  he  had  formed  as 
to  the  source  from  whence  the  matter  came,  and  he  requested  us  to  visit 
the  lady  with  him,  which  we  did  on  the  following  day.  On  examining 
the  case,  we  advised  the  immediate  removal  of  the  aflfected  teeth,  and 
the  more  strongly,  as  they  were  found  to  be  in  a  necrosed  condition. 

The  lady  readily  consented  to  the  operation,  which  was  performed 
on  the  following  day.  The  discharge  of  matter  from  behind  the  cur- 
tain of  the  palate  immediately  ceased",  and  the  patient  was  relieved 
from  an  affection  which  had  been  a  source  of  great  annoyance.  The 
jDus  from  the  abscess,  in  this  case,  instead  of  passing  out  through  the 
nasal  plates  of  the  superior  maxilla,  passed  back  over  the  roof  of  the 
mouth,  and  escaped  in  the  manner  described. 

The  author  was  lately  consulted  in  a  case  of  a  similar  character  to 
the  one  last  noticed.  The  pus  had  found  its  way  from  the  socket  of 
a  first  superior'  molar  to  about  the  centre  of  the  palatine  arch,  thence 
passed  up  into  the  posterior  nares,  and  was  discharged  from  behind 
the  velum  palati. 

Inflammation  of  the  investing  membrane  of  the  roots  of  an  inferior 
dens  sapientise  may  produce  equally  serious  effects,  without  occasioning 
the  formation  of  an  abscess  in  the  alveolus.  The  eruption  of  these  teeth 
is  sometimes  attended  with  like  consequences.  The  iri-itation  has,  in 
some  instances,  extended  to  the  lungs,  and  even  been,  in  decidedly 
consumptive  persons,  the  exciting  cause  of  consumption. 

The  occurrence  of  alveolar  abscess  in  the  cavity  of  a  temporary 
tooth  is  often  followed  by  exfoliation  of  the  sockets  of  several  teeth, 
and  sometimes  of  considerable  portions  of  the  jaw  bone,  seriously  in- 
juring the  rudiments  of  the  permanent  teeth,  and  sometimes  causing 
their  destruction.  The  author  saw  a  case,  a  few  years  since,  in  which 
an  abscess  of  the  alveolus  of  the  first  lower  temporary  molar  had  oc- 
casioned exfoliation  of  the  sockets  of  a  cuspid  and  two  molars.  About 
one-half  of  the  alveolar  cells  of  the  two  bicuspids  and  the  cuspid  of 
the  second  set  were  also  exfoliated,  thus  leaving  their  imperfectly 
formed  crowns  entirely  exposed. 
20 


306  DENTAL  PATHOLOGY,  THERAPEUTICS. 


CHAPTER  XIV. 

NECROSIS    AND    EXFOLIATION   OF   THE   ALVEOLAR   PROCESSES. 

THE  alveolar  processes,  as  well  as  other  osseous  structures,  are 
liable  to  necrosis  or  loss  of  vitality.  When  their  connection  with 
the  periosteum — the  source  from  whence  they  derive  their  nourishment 
and  vitality — is  destroyed,  death  follows  as  a  necessary  consequence. 
The  loss  of  vitality  may  be  confined  to  the  socket  of  a  single  tooth,  but 
more  frequently  it  extends  to  several,  and  sometimes  to  the  alveolar 
border,  occasionally  including  a  part  or  the  whole  of  the  jaw.  It  may 
occur  in  either  jaw,  but  it  is  more  liable  to  take  place  in  the  lower  than 
in  the  upper.  When  confined  to  the  alveoli,  the  dead  part  is  never 
replaced  with  new  bone,  but  examples  are  on  record  of  the  regenera- 
tion of  a  part,  and  even  the  whole  of  the  lower  jaw. 

When  one  or  more  of  the  cavities  of  the  teeth  lose  their  vitality, 
nature  exerts  all  her  energies  to  separate  the  dead  from  the  living 
bone ;  this  process,  technically  termed  exfoliation,  is  supposed  by  some 
to  consist  in  a  sort  of  suppurative  inflammation,  but  there  is  reason 
to  believe  it  is  effected  by  the  action  of  a  corrosive  fluid  poured 
out  from  the  fungous  granulations  of  the  living  bone  in  immedi- 
ate contact  with  the  necrosed  part.  During  the  process  of  exfoli- 
ation, a  thin  acrid  matter  is  discharged  from  one  or  more  fistulous 
opeuings  through  the  gums  or  from  between  them  and  the  necks 
of  the  teeth ;  the  gums  having  lost  their  connection  with  the  neci'osed 
bone,  become  soft  and  spongy,  and  assume  a  dark  purple  appearance, 
are  preternaturally  sensitive  to  the  touch,  and  bleed  from  the  most 
trifling  injury. 

In  the  admirable  work  of  Mr.  Fox,  on  the  Natural  History  and 
Diseases  of  the  Teeth,  the  case  of  a  gentleman  is  related  whose  left 
lateral  incisor  became  carious  ;  inflammation  and  pain  ensued,  together 
with  swelling  of  the  gums  and  lip.  Instead  of  consulting  a  physician, 
he  aj)plied  poultices  to  his  face,  until  suppuration  in  the  alveolus  took 
place,  causing  the  formation  of  an  external  opening  through  the  gums 
for  the  discharge  of  the  matter.  After  his  mouth  had  remained  for 
some  time  in  this  condition,  he  applied  to  Mr.  Fox,  who,  upon  exami- 
nation, found  that  not  only  had  the  decayed  tooth  become  loose,  but 
also  one  on  each  side  of  it.  The  first  he  extracted,  and  discovered  that 
the  alveolus,  from  the  destruction  of  the  periosteum,  was  quite  rough. 
The  adjoining  teeth,  still  continuing  loose,  were  in  a  few  weeks  removed, 


NECROSIS  AND  EXFOLIATION  OF  ALVEOLAR  PROCESSES.     307 

and  the  slight  force  that  was  applied  brought  with  them  the  alveolar 
process  of  the  whole  of  the  three  teeth,  and  also  a  considerable  portion 
of  the  jaw  bone. 

The  author  has  met  with  several  very  similar  cases,  although  all 
were  not  produced  by  the  same  cause,  and  he  has  several  specimens  in 
his  possession,  two  of  which  were  presented  to  him  by  his  brother,  the 
late  Dr.  John  Harris. 

He  has  also  met  with  two  cases  of  necrosis  and  exfoliation  of  the 
alveolar  processes,  which  are  worthy  of  special  notice.  The  subject  of 
the  first  case  was  a  gentleman  of  a  strumous  habit,  about  thirty  years 
of  age ;  the  necrosis  and  exfoliation  extended  to  the  cavities  of  all  the 
teeth  in  the  upper  jaw.  In  May,  1851,  he  had  the  nerve  destroyed  in 
the  second  bicuspid,  on  the  right  side  of  the  superior  maxilla.  We 
believe  it  was  afterward  removed,  and  the  pulp  cavity  and  root  filled. 
About  six  weeks  after,  as  nearly  as  we  could  ascertain,  the  cavity  of 
the  tooth  became  slightly  painful,  but  as  his  suffering  was  not  constant, 
he  supposed  it  would  soon  cease.  The  pain  ultimately,  however,  began 
to  increase,  and  by  the  latter  part  of  the  following  September  was  so 
severe,  and  attended  by  so  much  constitutional  disturbance,  that  he 
was  induced  to  consult  a  physician.  After  having  been  under  medical 
treatment  for  about  two  weeks,  the  author  was  requested  by  the  medi- 
cal attendant  to  see  him.  The  affected  tooth  was  found  to  be  loose, 
and  its  cavity  in  a  necrosed  condition  ;  inflammation  had  extended  to 
every  part  of  the  alveolar  border ;  the  gums  were  very  much  swollen, 
and  nearly  all  the  teeth  sensitive  to  the  touch.  As  the  patient  was 
laboring  under  considerable  cerebral  derangement,  and  as  no  advan- 
tage could  be  derived  from  the  removal  of  the  tooth  at  this  time,  it  was 
deemed  advisable  to  let  it  remain  until  exfoliation  of  the  necrosed 
cavity  should  take  place. 

Without  going  into  a  detailed  description  of  the  local  and  consti- 
tutional treatment  subsequently  pursued,  it  will  be  sufficient  to  state 
that  necrosis  extended  to  the  cavities  of  all  the  other  teeth,  except 
those  of  the  second  and  third  molars  on  each  side  of  the  mouth.  In 
the  course  of  about  two  mouths,  twelve  teeth,  together  with  their 
exfoliated  cavities,  and  several  large  pieces  of  the  maxillary  bone 
were  removed.  It  was  hoped  that  the  disease  would  stop  here, 
but  in  three  or  four  weeks  the  four  remaining  molars  became  very 
sore  to  the  touch,  and  as  purulent  matter  began  to  be  discharged 
from  their  sockets,  it  became  necessary  to  remove  them.  Several 
small  pieces  of  bone  were  exfoliated  after  the  last  operation,  but 
at  the  expiration  of  about  four  months  from  this  time  his  mouth 
was  sufficiently  restored  to  enable  him  to  wear  a  temporary  set  of 
artificial  teeth. 


308 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


The  subject  of  the  second  case  was  a  lady  of  a  cachectic  habit,  about 
thirty-five  years  of  age.  The  necrosis  resulted 
from  inflammation  of  the  alveolo-dental  perios- 
teum, occasioned  by  irritation  produced  by  the 
roots  of  four  incisors,  upon  which  pivot  teeth 
had  been  placed,  which,  however,  had  been  re- 
moved some  two  or  three  weeks  before  the 
author  saw  the  patient.  At  this  time  necrosis 
had  extended  uot  only  to  the  sockets  of  these  teeth,  but  also  up  to  the 
nasal  crest  of  the  maxillary  bone,  and  the  process  of  exfoliation  had 
already  proceeded  so  far,  that  he  was  enabled  to  remove  the  entire 
piece,  the  appearance  of  which  is  represented  in  Fig.  97.  In  July, 
1852,  a  few  weeks  after  the  removal  of  this  piece,  he  again  saw  the 
patient,  and,  on  examination,  found  a  large  portion  of  the  palatine 
plate  of  the  bone  in  a  ueci'osed  state ;  but  the  process  of  separation 
had  not  yet  proceeded  far  enough  to  enable  him  to  remove  it. 

The  accompaoying  engraving,  made  from  a  drawing  furnished  the 

author  by  Dr.  Maynard,  represents 
^^^-  ^^-  a  case  of  necrosis  and  exfoliation  of 

a  portion  of  the  outer  wall  of  the 
alveolar  ridge,  and  the  consequent 
protrusion  of  the  roots  of  the  teeth 
on  one  side  of  the  mouth.  The  only 
facts  which  Dr.  Maynard  had  been 
able  to  procure  in  relation  to  this 
case  were  contained  in  the  patient's  statement:  "That  in  1818  he  took 
a  cold,  which  settled  in  his  upper  jaw,  and  a  large  piece  of  the  jaw 
bone  came  away."  The  cast  from  which  the  drawing  was  made  was 
taken  in  1840,  at  which  time  the  doctor  cut  off  the  apices  of  several 
roots  which  projected  from  the  gums. 

The  alveolar  process  in  relation  with  the  superior  central  incisors 
appears  to  be  more  susceptible  to  necrosis  than  other  portions,  and 
this  may  be  ascribed  to  such  causes  as  diminished  vitality  occurring 
during  conditions  of  depression  and  debility,  the  liability  of  such  a 
prominent  part  to  mechanical  injury,  and  the  effect  of  suppurative 
inflammation  upon  a  portion  of  the  process  which  possesses  a  less 
degree  of  restorative  power  than  other  portions  better  protected  by 
muscular  tissue. 

Phosphor-Necrosis. — Necrosis  of  the  bones  of  the  jaws  may  also  result 
from  exposure  to  the  fumes  of  phosphorus,  as  in  the  manufacture  of 
matches,  for  example. 

The  disease,  when  due  to  such  a  cause,  usually  commences  about  a 
carious  tooth,  or  in  an  alveolar  cavity  opened  by  the  extraction  of  a 


NECROSIS  AND  EXFOLIATION  OF  ALVEOLAR  PROCESSES.     309 

tooth,  and  is  sometimes  complicated  with  affections  of  the  lungs  and 
air  passages. 

In  phosphor-necrosis  there  is  a  peculiar  pasty  appearance  of  the  face, 
pufliness  of  the  cheeks,  and  considerable  pain  and  swelling  in  the 
affected  jaw.  Instead  of  the  separation  of  a  sequestrum,  the  dead  bone 
becomes  incrusted  with  a  pumice-stone-like  material,  which  adheres 
very  firmly  to  it.  Abscesses  form  and  discharge  externally  through 
the  skin  of  the  cheek,  and  leave  fistulous  openings  for  the  escape  of 
the  matter. 

CAUSES. 

The  immediate  cause  of  necrosis  is  the  death  of  the  periosteum,  occa- 
sioned by  inflammation.  The  cause  of  this,  as  has  already  been  shown, 
is,  in  a  large  majority  of  the  cases,  dental  irritation.  Necrosis  of  the 
alveolar  process  occurs  very  frequently  w-hile  the  system  is  under  the 
influence  of  mercurial  medicines,  and  during  bilious  and  inflammatory 
fevers,  and  certain  other  constitutional  diseases,  as  syphilis,  smallpox, 
etc.  It  may  also  result  from  mechanical  injuries  and  the  devitalizing 
effect  of  such  agents  as  arsenious  acid  and  chloride  of  zinc,  when 
applied  to  destroy  pulps  of  teeth,  and  to  obtund  the  sensibility  of 
dentine,  etc.,  etc. 

TREATMENT. 

The  treatment  of  cases  of  this  kind  consists  in  the  removal  of  the 
sequestra,  strict  attention  to  cleanliness,  and  the  free  use  of  chlorinated 
washes.  As  soon  as  the  dead  portions  of  bone  become  separated  from 
the  living,  and  can  be  easily  removed,  they  should  be  taken  away  with  a 
pair  of  forceps.  Should  the  removal  of  a  considerable  portion  of  the 
bone  of  the  jaw  be  requisite,  it  is  seldom  necessary  to  interfere  with 
the  skin,  or  make  an  external  incision.  The  whole  of  the  lower  jaw 
can  be  removed  in  this  manner  by  dividing  it  at  the  chin,  and  after 
separating  all  the  attachments  of  the  soft  parts  with  the  knife,  drawing 
out  each  half  at  a  time. 

To  correct  the  offensive  odor  and  disagreeable  taste  occasioned  by 
the  constant  discharge  of  fetid  matter,  washes  of  chloride  of  sodium 
may  be  employed. 

There  is  no  remedy,  perhaps,  that  gives  more  satisfaction  in  the 
treatment  of  necrosed  alveolar  process,  and  carious  bone,  than  dilute 
aromatic  sulphuric  acid,  combined  with  a  small  quantity  of  tincture  of 
capsicum,  using  alternately  the  antiseptic  known  as  "listerine."  Prior 
to  the  application  of  such  agents,  the  diseased  parts  should  be  syringed 
with  tepid  water,  and  this  cleaning  process  continued  throughout  the 
entire  course  of  treatment.  While  cold  water  will  coagulate  pus  and 
unhealthy  secretions,  which  are  irritating  by  their  pressure,  warm  water 
will  produce  the  opposite  effect,  and  is  a  useful  adjunct  to  the  antiseptic 


310  DENTAL  PATHOLOGY,  THERAPEUTICS. 

remedies.  The  removal  of  teeth  in  cases  of  necrosis  of  the  alveolar 
process,  should  only  be  resorted  to  after  mature  consideration,  for  it 
frequently  happens  that  the  affection  is  confined  to  the  labial  walls, 
and  if  it  is  arrested  new  bone  may  be  formed  to  such  a  degree  as  to 
give  stability  to  the  teeth  in  relation  with  the  aflfected  part. 

Condy's  fluid,  or  a  solution  of  permanganate  of  potash,  a  weak  solu- 
tion of  carbolic  acid,  or  a  solution  of  chlorinated  soda,  will  answer  as 
disinfectants,  and  correct  the  fetor.  The  strength  of  the  patient  should 
be  supported  by  stimulants  and  tonics,  and  good  nourishment. 


CHAPTER  XV. 


ABSORPTION   OR   GRADUAL   DESTRUCTION   OF   THE   ALVEOLAR 
PROCESSES. 

WHILE  treating  of  inflammation  and  tumefaction  of  the  gums,  the 
author  adverted  to  the  wasting  of  the  sockets  of  the  teeth,  taking 
occasion  to  express  a  doubt  that  such  operation  of  the  economy  ever 
manifested  itself  in  the  absence  of  all  local  disease. 

It  is  always  accompanied  by  a  slight  increase  of  redness,  tumefaction, 
and  a  shrinkage  of  the  edges  of  the  gums  (ulatrophia)  ;  but  the  diseased 
action  here  is  so  inconsiderable  as  often  to  attract  little  attention. 
It  is  also  attended  by  a  slight  discharge  of  purulent  matter  from  between 
the  margin  of  the  gum  and  the  tooth ;  but  the  quantity  is  so  small  that 
it  usually  escapes  observation.  The  alveolo-dental  periosteum  partici- 
pates also  in  the  diseased  action,  but  this  is  so  slightly  aflfected  that 
the  tooth  often  remains  quite  firmly  articulated,  after  the  wasting  of  its 
socket  has  proceeded  even  so  far  as  to  expose  more  than  half  of  the  root. 
Indeed,  the  aflTection  is  so  closely  allied  to  chronic  inflammation  and 
tumefaction  of  the  gums,  as  scarcely  to  require  separate  consideration. 
The  progress  of  the  disease  is  usually  so  slow  that  ten,  fifteen,  or 
twenty  years  are  required  to  aflfect  very 
FiG^^9.  perceptibly   the    stability   of   the   teeth   in 

their  sockets.  The  commencement  of  this 
destructive  process  is  usually  first  observed 
around  the  cuspid  teeth  ;  sometimes  it  makes 
its  first  appearance  on  the  alveoli  of  the 
palatine  roots  of  the  first  and  second  upper 
molars,  and  occasionally  it  goes  on  here  for 
years  before  it  affects  the  sockets  of  any 
of  the  other  teeth. 


ABSORPTION   OF   THE   ALVEOLAR   PROCESSES.  311 

The  teeth,  after  their  roots  have  been  partially  exposed,  become,  as 
might  naturally  be  supposed,  more  susceptible  to  impression  from  heat 
and  cold,  and  more  easily  affected  by  acids,  or  saccharine  matters ;  but 
this  is  about  the  only  manifest  inconvenience  experienced  from  the 
disease,  until  the  teeth  begin  to  loosen  in  their  sockets. 

In  Fig.  99  is  represented  a  case  in  which  the  roots  of  the  teeth 
have  become  considerably  exposed  by  the  gradual  wasting  of  their 
sockets — the  destruction  being,  as  is  usual,  greatest  toward  the 
median  line. 

CAUSES. 

The  cause  of  this  peculiar  affection  has  never  been  very  satisfactorily 
explained.  Some  have  supposed  that,  inasmuch  as  it  occurs  most 
frequently  in  persons  of  advanced  age,  it  results  from  a  decline  of  the 
vital  powers  of  the  body,  independently  of  local  causes.  But,  as  it  is 
often  met  with  in  middle-aged  persons  whose  constitutional  health  is 
unimpaired,  we  doubt  the  correctness  of  the  opinion.  In  all  cases 
which  have  come  under  our  observation,  whether  in  middle-aged  or 
very  old  persons,  the  teeth  indicated  an  excellent  innate  constitution, 
whatever  may  have  been  the  state  of  the  general  health  at  the  time. 
In  every  instance  these  organs  were  possessed  of  great  density,  and 
this  fact  is  particularly  noticed  by  Mr.  Fox,  who  says : — 

"  In  a  majority  of  cases  in  which  this  disease  occurs,  the  teeth  are 
perfectly  sound,  and  from  numerous  observations,  we  think  we  may 
venture  to  assert  that  persons  who  have  had  several  of  their  teeth 
affected  with  caries  in  the  earlier  part  of  life,  are  not  liable  to  lose, 
by  an  absorption  of  their  sockets,  those  which  remain  sound ;  but, 
where  the  teeth  have  not  been  affected  with  caries  in  the  early  part 
of  life,  persons,  as  they  approach  the  age  of  fifty,  and  often  much 
earlier,  have  their  teeth  becoming  loose  from  absorption,  or  a  wasting 
of  the  alveolar  process." 

Now  it  is  evident  that  teeth  endowed  with  the  power  of  resisting  to 
so  late  a  period  of  life  the  action  of  the  causes  of  decay,  to  which  all 
teeth  are  more  or  less  exposed,  must  be  possessed  of  extreme  density, 
and,  necessarily,  a  corresponding  low  degree  of  vitality.  In  view  of 
this  fact,  we  have  been  led  to  the  opinion  that  the  teeth  themselves 
may  act,  to  some  extent,  as  mechanical  irritants  to  the  more  highly 
vitalized  parts  with  which  they  are  immediately  connected,  causing  an 
increase  of  vascular  action  in  the  periosteum  of  the  thin  edges  of  the 
alveoli  and  margin  of  the  gums.  This  abnormal  condition  is  attended 
by  a  slight  secretion  of  purulent  matter  observed  between  the  edges 
of  the  gums  and  teeth.  It  is  to  the  corrosive  action  of  this  purulent 
matter  that  the  gradual  destruction  of  the  alveoli  has  by  some  been 


312  DENTAL  PATHOLOGY,  THERAPEUTICS. 

attributed ;  but  it  is  more  probably  a  result  of  the  obscure  disease 
than  its  cause. 

This  affection  may  also  sometimes  result  from  the  presence  of  sali- 
vary calculus,  the  use  of  charcoal  powder  as  a  dentifrice,  and  the 
application  of  a  very  stiff  brush  for  cleaning  the  teeth ;  but  when 
caused  by  these  two  latter  agents,  the  absorption  does  not  progress 
to  such  a  degree  as  when  it  is  owing  to  a  want  of  congeniality 
between  the  tooth  and  the  moi-e  highly  vitalized  structures  sur- 
rounding its  root. 

TREATMENT. 

From  what  has  been  said  concerning  the  cauSe  of  this  affection, 
it  is  obvious  that  a  cure  cannot  always  be  effected ;  its  progress 
however,  may  sometimes  be  arrested.  The  first  step  in  the  treat- 
ment is  to  remove  all  irritants,  and  correct  the  nature  of  the  fluids 
of  the  mouth,  abnormal  in  character,  by  constitutional  treatment,  the 
use  of  lime-water,  and  a  detergent  dentifrice.  Should  such  means 
prove  ineffectual,  the  application  of  a  solution  of  iodine  and  creasote 
or  carbolic  acid  to  the  margins  of  the  gums  will  often  be  of  benefit  in 
retarding  the  absorption,  and  inducing  a  more  healthy  action.  The 
secretion  of  the  purulent  matter,  to  the  action  of  which  some  attribute 
the  destruction  of  the  alveoli,  is  the  result  of  a  disease  in  the  alveolo- 
dental  periosteum  and  edges  of  the  gums,  arising  from  some  peculiar 
physical  condition  of  the  teeth,  the  progress  of  which  may  be  retarded 
by  cleaning  the  teeth  frequently  and  thoroughly,  using  the  precaution 
each  time  to  remove  the  purulent  matter  from  between  the  edges  of 
the  gums  and  teeth,  lest,  if  allowed  to  remain,  it  should  become  putres- 
cent, and  in  this  condition  act  as  an  irritant  to  the  gum.  For  this 
purpose  a  brush  with  elastic  bristles  should  be  used,  and  much  benefit 
will  be  derived  by  passing  floss  silk  several  times  a  day  up  and  down 
between  the  teeth,  and  applying  a  solution  of  nitrate  of  silver,  twenty 
grains  to  the  ounce  of  water,  by  means  of  a  camel's-hair  brush,  to  the 
margins  of  the  gums.  When  salivary  calculus  causes  the  recession  of 
the  gum,  the  first  indication  is  the  removal  of  this  deposit.  As  the 
margin  of  the  gum  is  inflamed,  and  a  sulcus  or  pocket  formed  between 
it  and  the  tooth,  an  incision  should  be  made  from  the  bottom  of  this 
sulcus  upward,  and  the  tooth  surface  cleaned  and  polished.  This  treat- 
ment should  be  followed  by  the  application  of  carbolic  acid,  on  a  thin 
strip  of  orange  wood,  to  the  inner  surface  of  the  margin  of  the  gum,  to 
promote  healthy  granulations ;  a  weak  solution  of  chloride  of  zinc 
applied  in  the  same  manner,  is  also  recommended. 

The  judicious  application  of  pressure  upon  the  gum  has  in  some  cases 
restored  the  receded  portion,  to  a  degree,  at  least. 


HYPERTROPHY  OF  THE  ALVEOLAR  CAVITIES.  313 


CHAPTER   XVI. 

HYPERTROPHY   OF   THE   WALLS    OF   THE   ALVEOLAR   CAVITIES. 

A  TOOTH  is  sometimes  slowly  forced  from  its  place  by  a  deposit  of 
bony  matter  in  the  bottom  or  on  the  side  of  the  socket.  Two,  or 
even  three  teeth,  may  be  gradually  displaced  at  the  same  time,  by  ex- 
ostosis of  the  alveoli.  The  deposition  usually  proceeds  so  slowly  that 
one  or  two  years  are  required  to  effect  a  very  perceptible  change  in  the 
situation  of  a  tooth.  The  upper  central  incisors  are  more  frequently 
affected  than  any  of  the  other  teeth,  and  the  deposit  occurs  oftener  at 
the  bottom  than  on  the  sides  of  the  alveoli.  In  the  first  case,  the  tooth 
is  gradually  protruded  from  the  socket ;  in  the  other,  it  is  either  pressed 
out  of  the  arch,  or  against  one  of  the  adjoining  teeth.  Irregularity  in 
the  arrangement  of  the  teeth  is,  in  this  manner,  sometimes  produced, 
especially  when  more  than  one  socket  is  affected  at  the  same  time.  The 
central  incisors  are  sometimes  forced  apart ;  at  other  times  they  are 
forced  against  each  other,  and  caused  to  overlap.  The  deposition  of 
bone,  however,  being  generally  confined  to  the  bottom  of  the  sockets, 
the  teeth  are  more  generally  thrust  from  their  alveolar  cavities.  When 
this  occurs  with  a  person  whose  upper  and  lower  teeth  strike  directly 
upon  each  other,  it  occasions  much  inconvenience ;  for  the  elongated 
tooth  must  either  be  thrown  from  the  circle  of  the  other  teeth,  or,  by 
striking  its  antagonist,  prevent  the  jaws  from  coming  together. 

CAUSES. 

So  little  is  known  concerning  the  cause  of  exostosis  of  the  sockets  of 
the  teeth,  that  it  may  seem  almost  useless  to  attempt  .an  explanation  of 
it.  That  it  results  from  some  irritation  of  the  lining  membrane  is  very 
generally  believed,  but  what  causes  the  irritation  does  not  seem  to  be 
well  understood.  We  have  thought  that  it  might  sometimes  be  pro- 
duced by  pressure  on  the  bottom  of  the  alveolus,  especially  when  the 
extremity  is  nearly  as  large  as  any  other  part  of  the  root  of  the  tooth. 
The  susceptibility  of  the  lining  membrane  to  morbid  impressions  may 
sometimes  be  so  great  that  the  pressure  of  a  very  conical  root  may  be 
sufficient  to  produce  this  effect ;  or,  it  may  be  produced  by  the  pressure 
of  a  tooth  which  possesses  only  a  very  low  degree  of  vitality.  But  in 
connection  with  this  class  of  cases  must  be  taken  another,  in  which 
absence  of  all  pressure  would  seem  to  be  an  inciting  cause  of  alveolar 
exostosis ;  as  where  a  tooth  has  lost  its  antagonist  tooth  or  teeth,  and 


314  DENTAL  PATHOLOGY,  THERAPEUTICS. 

in  consequence  becomes  elongated.  A  diseased  state  of  the  gums  can 
have  no  agency  in  the  production  of  the  exostosis,  for  it  most  fre- 
quently occui'S  in  individuals  whose  gums  are  perfectly  healthy ;  and 
if  it  were  the  result  of  any  constitutional  tendency,  all  the  teeth  would 
be  as  likely  to  be  affected  by  it,  as  those  we  have  mentioned. 

TREATMENT. 

When  the  exostosis  is  on  the  side  of  the  alveolar  cavity,  the  tooth 
cannot  be  restored  to  its  natural  position  ;  but  when  it  is  in  the  bottom 
of  the  cavity,  the  elongated  organ  may  from  time  to  time,  as  it  is  forced 
from  the  alveolus,  be  filed  or  ground  off  even  with  the  other  teeth  ;  but 
in  doing  this,  care  should  be  taken  to  avoid  as  much  as  possible  the 
unpleasant  jar  which  the  file  or  corundum  disk  is  so  apt  to  cause,  and 
which  might,  in  such  cases,  excite  the  periosteum  to  increased  activity 
and  a  more  rapid  deposit.  This  will  remove  the  deformity  and 
prevent  its  displacement  by  the  antagonizing  tooth.  By  this  simple 
operation,  repeated  as  occasion  may  require,  it  is  preserved  for  years, 
and  rendered  almost  as  useful  as  any  of  the  other  teeth.  Steady 
pressure  in  the  proper  direction,  applied  to  the  crown  of  a  tooth  so 
affected,  may  also  prove  serviceable  at  an  early  stage. 


CHAPTER  XVII. 

ATROPHY   OP   THE   TEETH. 

THAT  peculiar  structural  alteration  of  the  teeth  designated  atrophy 
is  less  frequent  in  its  occurrence  than  any  other  disease  to  which 
these  organs  are  liable ;  but  as  the  progress  of  the  affection  usually 
terminates  with  the  action  of  the  causes  concerned  in  its  production,  it 
has  scarcely  been  deemed  of  sufficient  importance  to  merit  serious 
consideration.  Hence  its  etiology  and  pathology  have  not  been  very 
carefully  investigated.  Indeed,  most  writers  upon  the  diseases  of  the 
teeth  have  overlooked  the  affection  altogether ;  while  a  few  have 
merely  alluded  to  it,  without  describing  the  characteristics  of  even  its 
principal  varieties.  Whether  we  shall  now  be  able  to  throw  any 
additional  light  upon  the  subject,  or  establish  the  correctness  of  any 
opinions  already  advanced,  we  leave  to  others  to  determine. 

The  strict  applicability  of  the  term  atrophy  may,  perhaps,  be  con- 
sidered as  somewhat  questionable,  as  the  two  principal  varieties  of  the 
affection  consist  in  a  congenital  defect  in  some  portion  of  the  enamel 


ATROPHY   OF   THE   TEETH.  315 

of  two  or  more  teeth,  rather  than  in  the  wasting,  for  want  of  nourish- 
ment, of  any  of  the  dental  tissues.  This  term  would  seem  to  be  ren- 
dered still  more  inappropriate  by  the  fact  that  neither  of  the  varieties 
to  which  we  have  referred  occurs  subsequently  to  the  formation  of  the 
enamel.  But  as  the  congenital  form  of  the  disease  is  evidently  the 
result  of  altered  function  in  a  portion  of  one  or  more  of  the  formative 
organs — if  not  of  absolute  degeneration,  from  vicious  nutrition — we  are 
disposed  to  regard  the  term  as  the  most  applicable  of  any  tliat  can  be 
applied  to  it. 

Maury  treats  of  atrophy  and  erosion  as  one  and  the  same  disease. 
But  in  describing  atrophy  he  notices  the  distinctive  peculiarities  by 
which  each  affection  is  characterized.*  In  describing  the  difference 
between  erosion  and  atrophy,  M.  Delabarre  says,  the  part  atrophied 
is  deformed  and  deprived  of  the  enamel,  and  the  teeth  are  yellow 
and  sensitive,  the  touch  of  the  finger  causing  pain ;  but  in  erosion,  if 
the  crystals  of  the  enamel  are  not  wholly  destroyed,  the  bottom  of  the 
pits  are  of  a  white  color,  and  on  being  touched  no  disagreeable  sensa- 
tion is  experienced ;  if,  on  the  contrary,  the  crystals  are  destroyed  to 
the  dentine,  the  part  thus  denuded  is  irritable. 

In  an  article  on  erosion,  Maury  gives  a  very  accurate  description  of 
several  varieties  of  atrophy  of  the  teeth.  The  first,  he  represents  as 
consisting  of  deep,  irregular,  white  or  light  yellow  spots,  situated  in  the 
enamel  of  the  tooth,  without  affecting  the  smoothness  of  its  surface. 
The  second,  as  characterized  by  small  crowded  holes,  or  irregular 
depressions,  resembling  quilting;  or  as  consisting  of  transverse  sinu- 
osities, single  or  divided  by  prominent  lines,  which  are  sometimes 
"  yellow,  but  of  the  color  of  the  enamel."  The  third  variety  affects 
the  dentine  as  well  as  the  enamel,  reducing  the  dimensions  of  the  crown 
of  the  tooth  sometimes  to  one-third  its  natural  size,  and  not  unfre- 
quently  dividing  it  by  a  deep  circular  groove  or  depression. 

None  of  the  phenomena  here  described  are  produced  by  the  action 
of  corrosive  agents,  or  are  the  result  of  chemical  decomposition  either 
of  the  enamel  or  dentine,  but  are  manifestly  dependent  upon  other 
causes.  The  term  erosion,  therefore,  cannot  with  propriety  be  applied 
to  either  variety  of  the  affection  just  noticed.  Although  Maury  has 
given,  under  the  term  erosion,  a  better  description  of  the  principa 
varieties  of  dental  atrophy  than  any  other  writer,  he  has  omitted  some 
things  which  it  will  be  proper  to  mention.  In  treating  of  these  dif- 
ferent varieties,  therefore,  we  shall  change,  somewhat,  the  order  in 
which  he  has  arranged  them. 

Odontatrophia  may  very  properly  be  divided  into  three  varieties. 
Each  has  characteristic  peculiarities  which  distinguish  it  from  either 
*  Traits  Complet  de  I'Art  du  Dentiste,  pp.  99  and  100. 


316  DENTAL  PATHOLOGY,  THERAPEUTICS. 

of  the  others.  Two  are  always  congenital,  and  the  other,  although 
most  frequently  congenital,  sometimes  occurs  subsequently  to  the 
eruption  of  the  tooth. 

First  variety. — The  peculiarities  that  distinguish  this  variety  of 
atrophy  from  either  of  the  others  are,  that  it  never  impairs  the  uni- 
formity and  smoothness  of  the  surface  of  the  enamel,  and  is  character- 
ized by  one  or  more  white,  or  dark,  or  light  brown,  irregularly  shaped 
spots,  upon  the  labial  or  buccal  surface  of  the  tooth.  It  occurs  oftener 
than  the  third  variety,  and  less  frequently  than  the  second.  It  rarely 
appears  on  more  than  one  or.  two  teeth  in  the  same  mouth,  though 
several  are  sometimes  marked  by  it.  It  is  seen  on  the  molars  more 
frequently  than  the  bicuspids,  and  much  oftener  on  the  incisors  of  the 
upper  jaw  than  any  of  the  other  teeth.  We  do  not  recollect  to  have 
ever  observed  it  on  the  cuspids  of  either  jaw,  nor  on  the  palatini  or 
lingual  surfaces  of  the  incisors. 

The  enamel  is  much  softer  on  the  affected  than  on  the  unaffected 
parts  of  the  tooth,  and  may  be  easily  broken  and  reduced  to  powder 
"with  a  steel  instrument.  It  seems  to  be  almost  wholly  deprived,  in 
these  places,  of  its  animal  constituents,  and  to  have  lost  its  connection 
with  the  subjacent  dentine.  The  size  of  the  atrophied  spots  are  almost 
as  variable  as  their  shape,  but  the  only  harm  resulting  from  them  is 
the  unsightly  aspect  they  sometimes  give  to  the  tooth. 

As  we  have  before  remarked,  this  variety  of  atrophy  is  sometimes 
accidental,  occurring  subsequently  to  the  eruption  of  the  tooth,  but  in 
a  large  majority  of  cases  it  is  congenital.  It  is  rarely  seen  on  a 
temporary  tooth.  In  all  the  cases  which  have  come  under  our  obser- 
vation, it  was  confined,  to  the  best  of  our  recollection,  to  the  teeth  of 
second  dentition. 

Second  variety. — This  maybe  very  properly  denominated  Tser/ora^m^ 
or  pitting  atrophy ;  it  gives  to  the  enamel  an  indented  or  pitted  appear- 
ance, the  irregular  depressions  or  holes  extending  transversely  across 
and  around  the  tooth.  The  pits  are  sometimes  more  or  less  distinctly 
separated  one  from  another  by  prominent  lines ;  at  other  times  they 
are  confluent,  and  form  an  irregular  horizontal  groove.  Sometimes 
they  penetrate  but  a  short  distance  into  the  enamel ;  at  other  times 
they  extend  entirely  through  it  to  the  dentine.  Their  surface,  though 
generally  rough  and  irregular,  usually  presents  a  glossy  and  polished 
appearance — a  peculiarity  which  always  distinguishes  this  variety  of 
the  affection  from  erosion.  The  pits  often  have  a  dark-brownish  ap- 
pearance, though  sometimes  they  have  the  same  color  as  the  enamel  on 
other  parts  of  the  tooth. 

This  variety  of  atrophy  is  never  confined  to  a  single  tooth.  Two, 
four,  six,  or  more  corresponding  teeth  are  always  affected  at  the  same 


ATROPHY   OF   THE   TEETH.  317 

time  in  each  jaw;  and  the  corresponding  teeth  on  either  side  precisely 
in  the  same  manner  and  in  the  same  place.  When  more  than  two  are 
marked,  the  distance  of  the  pits  from  the  coronal  extremity  of  the 
tooth  varies,  according  to  the  progress  made  in  the  formation  of  the 
enamel  at  the  time  of  the  operation  of  the  causes  concerned  in  the  pro- 
duction of  the  affection.  For  example,  when  the  line  of  pits  in  the 
central  incisors  is  situated  about  two  lines  from  their  cutting  edges,  it 
will  scarcely  be  one  line  from  the  cutting  edges  of  the  laterals,  and 
only  the  points  of  the  cuspids  will  be  marked.  When  the  indentations 
are  nearer  the  edges  of  the  central  incisors,  they  will  be  on  the  edges 
of  the  laterals,  and  the  cuspids  will  have  entirely  escaped. 

Sometimes  the  teeth  are  marked  with  two  or  three  rows  of  pits,  and 
when  this  is  the  case,  the  patient  has  either  two  or  three  relapses ;  or 
has  been  attacked  two  or  three  times  in  succession  with  some  disease 
capable  of  interrupting  the  progress  of  the  formation  of  the  enamel. 

Although  the  incisors  are  more  frequently  marked  with  these  inden- 
tations than  any  of  the  other  teeth,  the  cuspids,  bicuspids,  and  even  the 
molars,  are  sometimes  affected  with  them.  When  the  disease  attacks 
the  molars,  its  effects  are  generally  located  on  the  grinding  surface. 
The  permanent  teeth  are  more  liable  to  be  attacked  than  the  tempo- 
rary. We  have  known  but  one  instance  in  which  the  latter  were 
affected  with  the  disease. 

This  variety  of  atrophy  occurs  oftener  than  either  of  the  others,  and 
though  it  sometimes  gives  to  the  teeth  a  disagreeable  and  unsightly 
appearance,  it  rarely  increases  their  liability  to  decay. 

Third  variety. — In  this  variety  of  atrophy  the  whole  or  only  a  part 
of  the  crown  of  a  tooth  may  be  affected  ;  the  dentine  being  often  im- 
plicated as  well  as  the  enamel.  The  tooth  usually  has  a  pale-yellowish 
color,  a  shriveled  appearance,  and  is  partially  or  wholly  divested  of 
enamel.  Sometimes  the  crown  is  not  more  than  one-half  or  one-third 
its  natural  size.  Its  sensibility  is  usually  much  increased,  and  its  sus- 
ceptibility to  pain  from  external  impressions  is  wonderfully  excited  by 
acids.  It  is  also  more  liable  than  the  other  teeth  to  be  attacked  by 
caries.  The  root  of  the  tooth  is  sometimes,  though  rarely,  affected, 
and  presents  an  irregular  knotted  appearance. 

The  disease  is  often  confined  to  a  single  tooth,  but  it  more  frequently 
shows  itself  on  two  corresponding  teeth  in  the  same  jaw.  According 
to  our  observation,  the  bicuspids  are  more  liable  to  be  attacked  than 
any  of  the  other  teeth.  The  temporary  teeth  are  rarely  affected  with 
it.  This  variety  of  atrophy  occurs  less  frequently  than  either  of  the 
others;  and,  although  it  increases  the  liability  of  the  affected  organs 
to  caries,  they  sometimes  escape  until  the  twentieth  or  thirtieth  year  of 
age. 


318  DENTAL  PATHOLOGY,  THERAPEUTICS. 

In  the  description  which  we  have  given  of  the  three  varieties  of 
dental  atrophy,  we  may  have  omitted  to  mention  some  of  the  peculi- 
arities belonging  to  each,  but  we  have  pointed  out  their  principal 
characteristics  with  sufficient  accuracy  to  enable  them  to  be  distin- 
guished one  from  another,  and  either  from  erosion. 

CAUSES. 

The  first  variety  is  evidently  produced  by  some  cause  capable  either 
of  preventing  or  destroying  the  bond  of  union  between  the  enamel  and 
subjacent  dentine,  but  what  that  cause  is,  becomes  a  question  which  it 
may  be  difficult  to  answer.  Subsequently  to  the  eruption  of  the  teeth, 
it  may  be  occasioned  by  mechanical  violence,  but  we  have  never  known 
more  than  one  case  in  which  it  had  resulted  from  this  cause,  and  that 
was  occasioned  by  a  blow  upon  the  tooth. 

Now,  whether  the  bond  of  union  between  this  portion  of  the  enamel 
and  the  subjacent  dentine  was  immediately  destroyed  by  the  concussion 
of  the  blow,  or  whether  it  resulted  from  subsequent  inflammation  and 
the  death  of  the  intermediate  membrane,  is  a  question  which  may  not 
be  easily  answered.  If  it  were  destroyed  at  once  by  the  blow,  one 
might  be  led  to  suppose  that  the  change  in  the  color  of  the  enamel 
would  have  been  observed  immediately ;  but  it  may  have  resulted 
from  some  subsequent  change  or  alteration  in  the  animal  constituents 
of  this  part  of  the  enamel,  following  as  a  consequence  of  the  injury 
produced  by  the  violence  of  the  blow.  These  are  questions,  however, 
which  the  present  state  of  our  knowledge  does  not  enable  us  to  solve. 
But  that  the  white  spot  in  this  case  resulted  as  a  consequence  of  the 
blow,  there  cannot  be  the  least  shadow  of  doubt. 

When  the  affection  is  congenital,  as  it  almost  always  is,  it  is  de- 
pendent upon  some  other  cause ;  possibly  upon  disease  in  the  pulp  or 
intermediate  membrane,  which  constitutes  the  bond  of  union  between 
the  dentine  and  enamel,  subsequently  to  the  formation  of  the  latter. 
But  what  the  determining  cause  of  the  disease  is,  whether  produced  in 
this  way  by  simple  local  irritation,  or  by  general  constitutional  dis- 
turbance, we  are  not  prepared  to  say.  One  would  be  likely  to  suppose 
if  the  atrophied  spots  were  occasioned  by  disease  of  the  pulp  or  inter- 
mediate membrane,  the  morbid  action  would  scarcely  confine  itself  to 
such  narrow  and  circumscribed  limits.  But,  whether  the  destruction 
of  the  intermediate  membrane  of  the  affected  parts  results  as  a  conse- 
quence of  actual  disease,  or  merely  from  vicious  nutrition,  or  whether 
from  unknown  causes  it  has  failed  to  be  developed  here,  it  is  certain 
that  the  fibres  of  this  portion  of  the  enamel  are  not  united  to  the  sub- 
jacent dentine;  thus,  not  receiving  a  supply  of  nutrient  fluid  or  vital 
principle,  their  animal  framework  partially  or  wholly  perishes,  leaving 


ATROPHY    OF   THE   TEETH.  319 

but  little  else  than  their  inorganic  constituents.  The  cause  of  this 
variety  of  congenital  atrophy,  it  must  be  confessed,  is  very  obscure; 
and,  in  the  absence  of  positive  knowledge,  we  can  only  infer  the  cause 
from  the  nature  of  the  affection.  If  it  does  not  result  from  one  or 
other  of  the  above-mentioned  causes,  it  is  difficult  to  imagine  in  what 
way  it  is  produced. 

The  cause  of  the  second  variety  of  odontatrophia  may  be  due  to 
some  constitutional  disease  which  may  interrupt  the  secretion  of  the 
earthy  salts  deposited  in  the  enamel  cells  or  secretory  ducts  of  the 
enamel  membrane,  for  the  formation  of  the  enamel  fibres ;  occurring 
at  the  time  when  this  process  is  going  on,  it  might  prevent  them  from 
being  filled,  and  cause  them  to  wither  or  waste  away,  giving  to  this 
portion  of  the  enamel  the  pitted  appearance  which  characterizes  this 
variety  of  atrophy.  In  other  words,  the  secretion  of  the  inorganic  con- 
stituents of  the  enamel  being  interrupted  for  a  short  time  the  horizontal 
row  of  cells  in  the  enamel  membrane,  into  which  it  should  be  deposited, 
will  not  be  filled ;  consequently,  as  might  readily  be  supposed,  they 
will  waste  away,  leaving  a  circular  row  of  indentations  around  the 
crown  of  the  tooth.  But  as  soon  as  the  constitutional  disease  has  run 
its  course,  the  secretion  of  the  earthy  salts  will  be  resumed  ;  and  unless 
the  child  experiences  a  relapse,  or  has  a  second  attack  of  disease,  capa- 
ble of  interrupting  this  secretory  process,  the  other  parts  of  the  enamel 
will  be  well  formed. 

Some  writers  ascribe  the  formation  of  these  pits  in  the  enamel  to  the 
chemical  action  of  a  corrosive  fluid,  or  to  an  acidulated  condition  of 
the  fluid  contained  in  the  dental  sacs ;  but  they  have  evidently  con- 
founded this  aflfection  with  erosion.  We  believe,  however,  it  almost 
always  occurs  as  a  consequence  of  some  eruptive  disease  or  catarrhal 
fever  occurring  during  the  "  enameling"  process;  and  there  are  many 
facts  which  go  to  sustain  the  correctness  of  this  opinion.  In  nearly 
all  the  cases  that  have  fallen  under  our  observation,  it  was  clearly 
traceable  to  measles,  scarlatina,  chicken-pox,  catarrhal  fever,  or  small- 
pox. It  may,  however,  occasionally  be  produced  by  other  constitutional 
diseases. 

The  third  variety  of  dental  atrophy,  so  far  as  our  observation  upon 
the  subject  has  permitted  us  to  form  an  opinion,  always  results  from 
altered  or  vicious  nutrition,  caused  by  disease  of  the  pulp  or  enamel 
membrane,  or  both,  during  the  secretion  of  the  dentine  or  enamel, 
accordingly  as  one  or  both  are  affected.  We  are  inclined  to  believe 
that  the  disease  in  the  dental  pulp  or  enamel  membrane  may  be  pro- 
duced either  by  local  or  constitutional  causes,  or  both.  But  the  infor- 
mation which  we  have  been  able  to  obtain  in  the  cases  that  we  have 
seen,  concerning  the  state  of  the  general  health,  and  that  of  the  mouth 


320  DENTAL  PATHOLOGY,  THERAPEUTICS. 

at  the  time  of  the  dentinification  of  the  pulp  and  the  secretion  of  the 
enamel,  has  not  been  as  satisfactory  as  we  could  have  wished. 

Since  writing  the  foregoing,  the  following  interesting  case  of  dental 
atrophy  has  fallen  under  our  observation : — 

Mrs.  C.  called,  in  1850,  to  consult  us  concerning  her  daughter's 
teeth,  which,  from  congenital  defect,  presented  a  most  unsightly  appear- 
ance. The  girl  was  between  nine  and  ten  years  of  age.  The  cutting 
edges  of  the  upper  central  incisors  were  badly  pitted  and  very  rough ; 
the  corresponding  teeth  in  the  lower  jaw  had  a  transverse  I'ow  of  pits 
passing  around  them,  about  a  sixteenth  of  an  inch  below  their  cutting 
extremities.  Another  row  of  pits,  so  close  together  as  to  form  a  rough 
groove,  encircled  the  U2:)per  central  incisors,  about  an  eighth  of  an  inch 
below  the  gum,  and  the  laterals  a  little  nearer  their  cutting  edges ; 
the  lower  incisors  were  similarly  marked,  but  not  quite  so  near  the 
gum.  The  enamel,  near  the  second  transverse  row  of  pits,  and  between 
it  and  the  cutting  edges  of  the  teeth,  was  thin  and  of  a  light-brown 
color.  A  little  above  the  first  row,  on  the  central  incisors,  were  two  or 
three  brown  or  opaque  spots.  The  first  permanent  molars  were  also 
encircled  with  a  row  of  indentations,  about  half-way  between  their 
grinding  surfaces  and  the  gums. 

On  inquiry,  we  learned  from  the  mother  that  the  child  had  a  light 
attack  of  measles  when  between  eleven  and  twelve  months  old,  of 
scarlet  fever  when  about  fifteen  or  sixteen  months  of  age,  and  dysen- 
tery at  about  the  twenty-first  or  twenty-second  month. 

Now,  here  we  have  the  three  varieties  of  atrophy  on  the  same  teeth ; 
and  the  occurrence  of  constitutional  diseases  about  the  time  when  the 
affected  parts  of  the  teeth  must  have  been  receiving  their  earthy  salts, 
would  seem  to  establish  very  conclusively  the  connection  of  the  one 
with  the  other, 

TREATMENT. 

The  nature  of  this  aflfection  is  such  as  not  to  admit  of  cure.  The 
treatment,  therefore,  must  be  preventive  rather  than  curative.  All 
that  can  be  done  is  to  mitigate  the  severity  of  such  diseases  as  are 
supposed  to  produce  it,  by  the  administration  of  proper  remedies.  By 
this  means  their  injurious  effects  upon  the  teeth  may,  perhaps,  be  par- 
tially or  wholly  counteracted. 

In  some  forms  of  this  affection  the  teeth  may  not  decay  more  readily 
than  others,  so  that  the  only  evil  resulting  from  the  affection  is  a  dis- 
figuration of  the  organs  ;  but  in  others,  and  especially  in  the  pitted 
variety,  it  may  be  necessary  to  insert  fillings  at  an  early  age.  When 
the  cutting  edges  of  the  incisors  only  are  affected,  the  diseased  part 
may  sometimes  be  removed  without  injury  to  the  teeth. 


NECROSIS   OF  THE   TEETH.  321 


CHAPTER  XVIII. 

NECROSIS   OF   THE   TEETH, 

BY  the  term  necrosis,  when  applied  to  a  tooth,  is  meant  the  death 
of  the  entire  organ,  or  of  the  crown  and  inner  walls  of  the  root  ; 
for  it  often  happens  that  a  degree  of  vitality  is  kept  up  in  the  outer 
portion  of  the  dentine  and  the  investing  cementum  by  the  peridental 
membrane  long  after  the  destruction  of  the  pulp  and  lining  membrane. 
When  other  bones  are  affected  with  necrosis,  the  dead  part  is  thrown 
off  and  the  loss  supplied  by  the  formation  of  new  bone.  But  the  teeth 
are  not  endowed  with  the  recuperative  power  which  the  process  of  ex- 
foliation calls  for. 

The  density  of  a  tooth  is  not  sensibly,  if  at  all,  affected  by  the  mere 
loss  of  vitality ;  but  so  great  a  change  takes  place  in  the  appearance 
of  the  organ,  that  it  may  readily  be  detected  by  the  most  careless 
observer.  After  the  destruction  of  the  lining  membrane,  the  tooth 
gradually  loses  its  peculiar  semi-translucent  and  animated  appearance, 
assuming  a  dingy  or  muddy  brown  color;  and  this  change  is  more 
striking  in  teeth  of  a  soft  than  in  those  of  a  hard  texture.  The  dis- 
coloration, too,  is  always  more  marked  when  the  loss  of  vitality 
has  resulted  from  a  blow,  than  when  produced  in  a  more  gradual 
manner.  The  discoloration  is  partly  owing  to  the  presence  of  disor- 
ganized matter  in  the  pulp  cavity,  and  partly  to  the  absorption  of  this 
matter  by  the  surrounding  walls  of  dentine. 

After  the  destruction  of  the  lining  membrane,  the  tooth  may  receive 
a  sufficient  amount  of  vitality  from  the  alveolo-dental  periosteum  to 
prevent  it  from  exerting  a  manifest  morbid  influence  upon  the  parts 
with  which  it  is  immediately  connected.  Teeth  have  been  retained 
under  such  circumstances  with  apparent  impunity  for  many  years. 
But  when  every  part  of  a  tooth  has  lost  its  vitality,  it  becomes  an  ex- 
traneous body.  When  this  hajDpens,  inflammation  of  the  cavity  ensues, 
the  gum  around  it  becomes  turgid  and  spongy,  and  bleeds  from  the 
slightest  injury,  and  the  organ  gradually  loosens  and  ultimately  drops 
out.  In  the  meantime  the  diseased  action  frequently  extends  to  the 
cavities  and  gums  of  the  adjoining  teeth. 

The  front  teeth  being  more  exposed  to  injuries  from  violence,  are 
more  liable  to  necrosis  than  the  molars. 


21 


322  DENTAL   PATHOLOGY,  THERAPEUTICS. 

CAUSES. 

Necrosis  of  the  teeth  may  be  produced  by  a  variety  of  causes,  such 
as  protracted  fevers,  the  long-continued  use  of  mercurial  medicines, 
by  caries  and  by  external  violence.  The  immediate  cause,  however, 
when  not  occasioned  by  a  blow  sufficient  to  destroy  the  vascular  con- 
nection of  the  tooth  with  the  rest  of  the  system,  is  inflammation  and 
suppuration  of  the  lining  membrane  ;  but  it  may  result  from  deficiency 
of  vital  energy  and  from  impaired  nutrition ;  for  the  author  has  met 
with  several  cases  in  which  the  loss  of  vitality  could  not  be  accounted 
for  in  any  other  way. 

TREATMENT. 

When  a  tooth,  deprived  of  vitality,  is  productive  of  injury  to  the 
gums  and  to  the  adjacent  teeth,  it  should  be  immediately  removed  ;  for, 
however  important  or  valuable  it  may  be,  the  health  and  durability  of 
■the  others  should  not  be  jeopardized  by  its  retention. 

When  necrosis  of  a  tooth  is  apprehended,  we  should  endeavor  to 
prevent  its  occurrence,  by  the  application  of  leeches  to  the  gums,  and 
by  gargling  the  mouth  with  suitable  astringent  washes,  and  the  employ- 
ment of  such  remedies  as  are  useful  in  the  treatment  of  alveolo-dental 
periostitis.  If  this  plan  of  treatment  is  adopted  at  an  early  period,  it 
will  sometimes  prevent  the  loss  of  vitality ;  but  if  long  neglected,  a 
favorable  result  need  not  be  anticipated. 

When  the  loss  of  vitality  is  confined  to  the  crown  and  inner  walls 
of  the  root,  if  the  former  is  not  seriously  impaired  by  caries,  it  may 
be  perforated,  and  the  pulp  cavity  and  root  cleansed  and  filled  in  the 
manner  as  directed  in  another  part  of  this  work.  If  the  necrosed  tooth 
is  an  incisor,  the  perforation  should  be  made  from  the  palatal  surface, 
provided  the  proximate  surfaces  are  sound.  But  previously  to  the 
introduction  of  a  filling,  the  decomposed  surface  of  the  walls  of  the 
pulp  cavity  should  be  completely  removed,  and  if  this  does  not  restore 
the  tooth  to  its  natural  color,  the  process  of  bleaching  should  be 
resorted  to. 

Bleaching  Necrosed  Teeth. — To  improve  the  appearance  of  a  necrosed 
tooth  which  has  become  discolored  from  the  dentinal  tubuli  absorbing 
the  coloring  matter  from  the  blood,  the  following  method  may  be  pui'- 
sued :  First,  remove  all  decayed  matter  from  the  crown  cavity,  where 
such  a  cavity  exists,  taking  care,  however,  to  leave  the  enamel  unin- 
jured, and  also  as  much  of  the  dentine  as  is  necessary  for  the  strength 
of  the  tooth.  Pursue  the  same  course  with  regard  to  the  canal  in  the 
root,  cleansing  this  carefully  by  means  of  a  syringe  and  tepid  water, 
after  the  removal  of  decomposed  matter  with  the  nerve  canal  instru- 
ments. When  the  discoloration  is  recent,  and  not  more  than  a  red 
tinge  in  degree,  such  treatment  as  has  been  described  may  prove 


NECROSIS   OF   THE  TEETH.  323 

sufficient ;  should  it  not  be,  however,  owing  to  the  length  of  time  the 
discoloration  has  existed,  and  the  hue  is  a  brown,  dark  brown  or  black, 
it  is  then  necessary  to  resort  to  such  agents  as  contain  chlorine.  Solu- 
tions of  chloride  of  soda,  chloride  of  lime,  chlorate  of  potash,  decompose 
organic  substances  by  removing  the  hydrogen  of  their  coloring  matter. 
One  of  the  most  reliable  of  these  preparations  is  the  solution  of  chloride 
of  soda,  known  as  "Labarraque's  Disinfecting  Fluid,"  which  may  be 
introduced  on  a  pellet  of  cotton,  and  allowed  to  remain  in  the  tooth 
from  thirty  to  sixty  minutes,  according  to  the  degree  of  discoloration 
present.  Repeated  applications  may  be  necessary  in  some  cases  before 
the  object  desired  is  accomplished.  To  prevent  the  caustic  action  of 
these  agents  on  the  soft  parts,  the  canal  in  the  root  should  be  partly 
filled  prior  to  their  introduction,  and  care  taken  to  prevent  their 
coming  in  contact  with  the  mucous  membrane  of  the  mouth.  The 
chloride  of  lime  is  introduced  in  the  same  manner  as  the  chloride  of 
soda,  and  is  allowed  to  remain  for  five,  ten,  or  fifteen  minutes  at  a  time, 
and  its  application  repeated  if  necessary,  the  crown  cavity  during  the 
interval  being  protected  by  a  temporary  filling  of  Hill's  stopping. 

Dry,  fresh  chloride  of  lime  made  into  a  paste  with  dilute  tartaric 
acid  has  given  satisfaction  in  many  cases  as  a  bleaching  preparation ; 
and  in  recent  cases,  or  in  slightly  discolored  teeth,  the  plastic  filling 
material  known  as  oxychloride  of  zinc,  introduced  into  the  crown 
cavity  and  worn  as  a  temporary  filling,  has  been  effective  in  improving 
the  appearance  of  a  discolored  crown.  Oxalic  acid  carefully  applied 
and  protected,  is  also  effective  as  a  bleaching  agent,  applied  in  the  form 
of  a  crystal  introduced  into  the  carious  cavity  and  dissolved  by  ap- 
plying to  it  a  drop  of  water.  Cyanide  of  potassium  in  solution  will 
remove  the  stains  caused  by  old  amalgam  fillings,  but  must  be  employed 
with  great  care,  as  it  is  a  very  active  and  deadly  poison.  In  the  use 
of  all  these  agents,  it  must  be  remembered  that  upon  the  cause  of  the 
discoloration  will  depend  the  efficacy  of  the  chemical  agent,  and  that 
chlorine  will  answer  in  some  cases,  owing  to  the  nature  of  the 
agents  instrumental  in  producing  the  discoloration,  while  cases  of  dis- 
coloration arising  from  the  action  of  other  agents,  will  require  such 
preparations  as  oxalic  acid,  etc. 

After  the  action  of  the  bleaching  agent  is  no  longer  required,  a  good 
practice  is  to  fill  the  crown  cavity  of  the  tooth  with  either  prepared 
chalk,  or  carbonate  of  magnesia,  which  may  be  secured  by  a  temporary 
filling,  and  permitted  to  remain  for  several  days  ;  or  a  filling  of  the 
oxychloride  of  zinc  may  be  temporarily  used,  and  a  more  permanent 
filling  be  subsequently  introduced.  Chloride  of  zinc  in  the  form  of 
crystals  may  also  be  employed  as  a  bleaching  agent;  also  chlorine  water 
injected  repeatedly  by  means  of  a  syringe ;  also  chlorate  of  potash 


324 


DENTAL   PATHOLOGY,  THEEAPEUTICS. 


and  chloride  of  alumina.  It  should  be  remembered  that  the  effect  of 
these  agents  is  to  remove  the  organic  or  animal  matter  from  the  tooth 
structure,  and  that  their  repeated  application  may  cause  the  crown  of 
the  tooth  to  become  frail  and  brittle. 


CHAPTER  XIX. 


EXOSTOSIS   OF   THE   TEETH. 


Fig.  100, 


THIS  disease  is  common  to  all  bones,  but  it  attacks  no  other  part  of 
a  fully  formed  tooth  than  the  root ;  for  in  the  cementum  alone,  of 
the  three  osseous  dental  tissues,  do  we  find  that  degree  of  vascularity 
which  is  a  necessary  condition  of  growth — normal  or  abnormal.  It 
usually  commences  at  or  near  the  extremity,  then  extends  upward, 
covering  a  greater  or  less  portion  of  the  external  surface.  It  some- 
times, however,  commences  upon  the  side  of  the  root  and  forms  a  large 
tubercle ;  at  other  times  the  deposit  of  the  new  bony  matter  is  spread 
over  its  surface,  often  uniformly,  but  more  frequently  unequally.  The 
osseous  matter  thus  deposited,  has  usually  the  color,  consistence  and 
structure  of  the  cementum,  though  sometimes  it  is  a  little  harder  and 
assumes  a  yellower  tinge.  The  enlargement  is  in  fact 
an  hypertrophied  condition  of  this  substance.  Those 
singular  anomalies,  occasionally  met  with,  where 
enamel,  dentine  and  cementum  are  mixed  up  in  a 
shapeless  confusion,  are  no  exceptions  to  the  rule 
that  exostosis  is  confined  to  the  cementum ;  for 
though  classed  under  this  head,  these  cases  arise 
from  the  disruption  of  the  formative  membranes 
(possibly  the  result  of  violence),  each  secreting  its 
peculiar  tissue.  The  hypertrophy  is  probably  con- 
fined to  the  dentine;  yet  it  is  quite  possible  for  the 
dentinal  and  enamel  membranes  in  their  then  vas- 
cular condition  to  have  an  excess  of  development. 

The  deposit  of  osseous  matter  is  sometimes  so  con- 
siderable that  the   roots  of  two  or  more  teeth  are 
firmly  united  by  it.    Fig.  100  represents  some  examples  of  exodontosis 
of  this  description. 

An  extraordinary  case  of  dental  exostosis  was  sent  to  the  author  for 
examination,  by  Dr.  V,  M.  Swayze,  of  Easton,  Pa,  The  tooth  appa- 
rently is  a  dens  sapientise,  and  the  formation  of  the  exostosis  must  have 


EXOSTOSIS   OF   THE   TEETH.  325 

commenced  with  the  doutinification  of  the  pulp.  It  had  spread  over 
every  part  of  the  tooth,  the  crown  as  well  as  the  root ;  it  had  ruptured 
and  penetx'ated  every  part  of  the  enamel  membrane,  but  had  not  wholly 
destroyed  the  function  of  this  organ,  as  nodules  of  enamel  are  seen  in 
various  parts  of  the  exostosis.  The  tumor,  including  the  tooth,  is  about 
as  large  as  a  common-sized  hickory  nut. 

In  one  instance,  the  author  was  compelled  to  extract  four  sound 
teeth  and  nine  roots ;  yet  the  pain  was  not  at  any  time  severe,  but  it 
was  constant,  and  a  source  of  great  annoyance  to  the  patient.  The 
following  is  one  among  the  many  cases  which  have  fallen  under  his 
observation  : — 

Mr.  S.,  of  Baltimore,  in  the  Fall  of  1845,  called  upon  us  for  advice. 
Having  for  some  time  suffered  pain  in  the  first  left  superior  bicuspid, 
he  had  applied  two  years  before  to  a  dentist  for  the  purpose  of  having 
the  tooth  removed.  In  the  operation,  the  root,  about  three-sixteenths 
of  an  inch  from  its  extremity,  was  fractured  and  left  in  the  socket. 
In  consequence  of  this,  the  gnawing  pain  with  which  he  had  for  a  long 
time  before  been  troubled,  continued,  and  at  the  expiration  of  twelve 
months  the  gum  over  the  remaining  portion  of  the  root  became  very 
much  swollen,  pufiing  out  the  lip  to  the  size  of  half  a  hen's  egg.  The 
tumor,  after  a  few  days,  was  opened,  and  a  large  quantity  of  dark- 
colored,  fetid,  purulent  matter  was  disch^-rged,  which,  for  a  short  time, 
gave  considerable  relief.  The  tumor,  however,  was  re-formed,  and 
opened  some  four  or  five  times  in  as  many  months.  At  this  time  his 
gum  was  swollen,  and  the  upper  lip  puffed  out  in  the  manner  just  de- 
scribed. On  opening  the  tumor,  about  three  tablespoonfuls  of  black 
matter,  resembling  thin  tar,  escaped.  We  then  found,  upon  examina- 
tion, that  the  outer  wall  of  the  antrum,  immediately  over  the  remain- 
ing portion  of  the  root  of  the  first  bicuspid,  was  destroyed,  and  there 
was  an  opening  through  it  large  enough  to  admit  the  forefinger.  Be- 
lieving that  the  extremity  of  the  root  left  in  the  socket  was  the  cause 
of  the  disease,  we  immediately  proceeded  to  extract  it,  which  we  suc- 
ceeded in  doing  after  removing  the  outer  wall  of  the  alveolus.  The 
root  was  found,  on  removal,  to  be  enlarged  by  exostosis  to  the  size  of 
a  very  large  pea.  The  operation  proved  perfectly  successful,  the 
secretion  of  purulent  matter  soon  ceased,  and  in  a  few  weeks  he  was 
completely  relieved  from  the  troublesome  affection  under  which  he 
had  so  long  labored. 

Several  years  ago.  Prof.  Gorgas,  while  demonstrating  practical 
anatomy,  discovered  all  the  teeth  in  the  mouth  of  one  of  the  subjects 
(a  negro  girl  about  twenty-five  years  of  age)  to  be  in  an  exostosed  con- 
dition. On  the  roots  of  one  of  the  superior  molar  teeth  the  deposit  of 
osseous  matter  measured  three-fourths  of  an  inch  in  diameter. 


326  DENTAL  PATHOLOGY,  THERAPEUTICS. 

Teeth  affected  with  exostosis  may  be  free  from  tenderness  even 
under  pressure  or  percussion,  although  the  gum  may,  in  some  cases, 
be  slightly  congested. 

In  many  but  not  in  all  cases  of  dental  exostosis  more  or  less  pain 
attends  this  affection,  owing  to  the  enlargement  of  the  cementum  with 
consequent  pressure  upon  the  nerves.  When  such  an  enlargement  is 
in  proportion  to  that  of  the  alveolus,  little  or  no  pain  may  be  experi- 
enced. The  pain  arising  from  the  enlargement  of  the  cementum  is  at 
times  moderate  though  persistent,  but  in  some  cases  it  may  be  excruci- 
ating, and  may  be  referred  to  distant  parts  of  the  face  and  head  or 
ear  and  about  the  terminal  branches  of  the  fifth  pair  of  nerves,  thus 
resembling  neuralgia. 

CAUSES. 

The  primary  cause  of  this  disease  does  not  appear  to  be  well  un- 
derstood. Most  writers  concur  in  attributing  the  proximate  cause  to 
irritation  of  the  periosteum  of  the  root ;  but  this  is  not,  as  some  sup- 
pose, necessarily  dependent  upon  any  morbid  condition  of  the  crown 
itself,  for  it  often  attacks  teeth  that  are  perfectly  sound.  It  seems 
rather  to  be  attributable  to  some  peculiar  constitutional  diathesis. 

TREATMENT. 

When  it  is  possible  to  discover  the  existence  of  dental  exostosis  at 
an  early  stage,  iodide  of  potassium  in  large  doses,  and  painting  the 
gum  over  the  affected  root  with  such  counter-irritants  as  a  saturated 
tincture  of  iodine,  or  cantharidal  collodion  to  produce  a  blister. 

The  disease  having  established  itself  does  not  admit  of  cure,  and 
when  it  has  progressed  so  far  as  to  be  productive  of  pain  and  incon- 
venience to  the  patient,  the  loss  of  the  affected  teeth  becomes  inevitable. 
When  the  enlargement  is  very  considerable  and  confined  to  the  ex- 
tremity of  the  root,  and  has  not  induced  a  correspondent  enlargement 
of  the  alveolus  around  the  neck  of  the  tooth,  the  extraction  of  the 
affected  organ  is  often  attended  with  difiiculty,  and  can  only  be  accom- 
plished by  removing  a  portion  of  the  alveolar  wall  of  the  cavity,  or 
fracturing  it.  . 

Some  are  of  the  opinion,  however,  that  the  deposit  of  osseous  matter 
may  be  arrested  and  absorption  excited  so  as  to  make  room  for  that 
already  deposited,  by  the  administration  of  iodide  of  potassium,  as 
referred  to  above. 


DENUDING  OF  THE  TEETH.  327 


CHAPTER  XX. 

DENUDING   OF   THE   TEETH. 


THIS  is  one  of  the  most  remarkable  aiFections  to  which  the  teeth 
are  liable.  It  consists  in  the  gradual  wasting  of  the  enamel  on 
the  labial  surfaces,  attacking  first  the  central  incisors,  then  the  laterals, 
afterward  the  cuspids  and  bicuspids,  extending  sometimes  to  the  first 
and  second  molars.  It  usually  forms  a  continuous  horizontal  groove, 
as  regularly  and  smoothly  constructed  as  if  it  had  been  made  with  a  file. 
(See  Fig.  101.)     After  it  has  removed  the  enamel,  it  commits  its  rav- 

FiG.  101.  Fig.  102. 


ages  upon  the  subjacent  dentine,  sometimes  penetrating  to  the  pulp 
cavity.  It  rarely  changes  the  color  of  the  enamel,  but  the  dentine, 
after  it  becomes  exposed,  assumes  first  a  light,  and  afterward  a  dark 
brown  color ;  retaining,  however,  a  smooth  and  polished  surface.  This 
destructive  process  does  not  always  commence  at  merely  one  point  on 
the  labial  surface  of  the  central  incisors,  as  just  described ;  it  some- 
times attacks  several  points  simultaneously.  (See  Fig.  102.)  As  it 
spreads,  these  unite,  and  ultimately  a  deep  excavation  is  formed,  with 
walls  so  smooth  and  highly  polished  that  the  tooth  presents  the  ap- 
pearance of  having  been  scooped  out  with  a  broad,  square,  or  round- 
pointed  instrument. 

The  progress  of  the  affection  is  exceedingly  variable.  It  is  some- 
times so  rapid  that  the  dentine  becomes  exposed  within  two  or  three 
years  from  the  commencement  of  the  disease ;  at  other  times  its  effect 
upon  the  enamel  is  scarcely  perceptible  for  the  first  six  or  eight  years 
after  it  makes  its  appearance.  In  the  case  of  a  lady  whose  teeth  were 
thus  affected,  the  denuding  process  did  not  perforate  the  enamel  for 
nearly  twenty  years.  The  dentine,  after  it  is  denuded  of  enamel,  is 
generally  quite  sensitive,  and  very  susceptible  to  heat  and  cold. 

CAUSES. 

The  cause  of  this  singular  affection  has  never  been  satisfactorily  ex- 
plained. It  was  first  noticed  by  Mr.  Hunter,  who  calls  it  decay  by 
denudation,  and  supposes  that  it  is  a  disease  inherent  in  the  tooth 


328  DENTAL  PATHOLOGY,  THERAPEUTICS. 

itself,  and  not  dependent  on  circumstances  in  after  life,  for  the  reason 
that  it  attacks  certain  teeth  rather  than  others,  and  is  often  confined 
to  a  particular  tooth. 

Some  writers  suppose  it  is  occasioned  by  the  friction  of  the  lips. 
But  this  hypothesis  is  destitute  of  the  least  semblance  of  plausibility ; 
for  the  narrowness  and  depth  of  the  grooves  are  sometimes  such  as  to 
preclude  the  possibility  of  the  contact  of  the  lips  with  their  surfaces. 

Some  eminent  practitioners,  again,  attribute  it  to  the  use  of  tooth- 
brushes. That  this  may  increase  the  size  of  the  horizontal  groove  is 
more  than  probable ;  that  it  may  even  in  some  cases  determine  the 
commencement  of  the  groove,  is  just  possible.  But  no  conceivable 
action  of  the  brush  could  be  an  inciting  cause  of  that  form  of  the  dis- 
ease shown  in  Fig.  102.  There  is  better  reason  for  believing  that  this 
affection  is  due  to  a  condition  of  enamel  deficient  in  vital  resistance, 
owing  to  some  modification  at  the  period  of  its  formation,  thus  render- 
ing it  susceptible  to  the  action  of  agents  which  it  might  under  more 
favorable  circumstances,  successfully  resist,  such  as  an  acid  contained 
in  the  mucus. 

TREATMENT. 

In  advanced  stages  of  the  affection,  its  progress  may  be  arrested 
by  properly  preparing  the  cavities,  and  afterwards  filling  them  with 
gold.  This,  in  the  majority  of  cases,  will  prove  successful.  Should 
the  grooves  or  pits  become  discolored,  it  will  be  proper  to  use  occa- 
sionally pumice  or  silex  applied  on  a  point  of  wood. 


CHAPTER  XXI. 

CHEMICAL   ABRASION   OF   THE   TEETH. 

THE  chemical  abrasion  ("  corrosion,"  perhaps,  would  be  a  better 
term)  of  the  cutting  edges  of  the  front  teeth  is  an  affection  of  very 
rare  occurrence.  It  commences  on  the  central  incisors,  proceeding 
thence  to  the  laterals,  the  cuspids,  and  sometimes,  though  very  rarely, 
to  the  first  bicuspids.  Teeth  thus  affected  have,  when  the  jaws  are 
closed,  a  truncated  appearance;  the  upper  and  lower  teeth  do  not  come 
together,  and  they  are  rather  more  than  ordinarily  susceptible  to  the 
action  of  acids,  or  of  heat  and  cold.  In  other  respects,  little  or  no  in- 
convenience is  experienced  until  the  crowns  of  the  affected  teeth  are 
nearly  destroyed. 

Its  progress,  as  in  the  case  of  abrasion  of  the  labial  surfaces,  is 


CHEMICAL   ABRASION   OF   TUB   TEETH.  329 

exceedingly  variable.  It  sometimes  destroys  half  or  two-thirds  of  the 
crowns  of  the  central  incisors  iu  two  or  three  years ;  at  other  times 
seven  or  eight  years  are  required  to  produce  the  same  effect.  In  one 
case  which  came  under  our  own  observation,  the  abrasion  had  extended 
to  the  bicuspids,  and  the  central  incisors  of  both  jaws  were  so  much 
wasted,  that  on  closing  the  mouth  they  did  not  come  together  by 
nearly  three-eighths  of  an  inch ;  yet  two  years  only  had  elapsed  since 
its  commencement.  In  another  case,  where  it  had  been  going  on  for 
seven  years,  it  had  not  extended  to  the  cuspids,  and  the  space  between 
the  upper  and  lower  incisors  did  not  exceed  an  eighth  of  an  inch. 
The  subjects  of  these  two  were  gen- 
tlemen— the  first  aged  about  twen-  ■^^^-  ^^^• 
ty-eight,  and  the  other  twenty-one. 
Mr.  Bell  gives  an  interesting  case 
(Fig.  103)  of  a  gentleman  w^hose 
teeth  were  thus  affected :  "  About 
fourteen  months  since  (1831),  this 
gentleman  perceived  that  the  edges 

of  the  incisors,  both  above  and  below,  had  become  slightly  worn  down, 
and,  as  it  were,  truncated,  so  that  they  could  no  longer  be  placed  in 
contact  with  each  other.  This  continued  to  increase  and  extend  to 
the  lateral  incisors,  and,  afterward,  successively,  to  the  cuspids  and 
bicuspids.  There  has  been  no  pain,  and  only  a  trifling  degree  of  un- 
easiness, on  taking  acids,  or  any  very  hot  or  cold  fluids,  into  the  mouth. 
When  I  first  saw  these  teeth,  they  had  exactly  the  appearance  of  hav- 
ing been  most  accurately  filed  down  at  the  edges,  and  then  perfectly 
and  beautifully  polished  ;  and  it  has  now  extended  so  far  that  when 
the  mouth  is  closed  the  anterior  edges  of  the  incisors  of  the  upper  and 
lower  jaws  are  nearly  a  quarter  of  an  inch  asunder.  The  cavities  of 
those  of  the  upper  jaw  must  have  been  exposed,  but  for  a  very  curious 
and  beautiful  provision  ;  they  have  become  gradually  filled  by  a 
deposit  of  new  bony  matter,  perfectly  solid  and  hard,  but  so  trans- 
parent that  nothing  but  examination  by  actual  contact  could  convince 
an  observer  that  they  were  actually  closed.  This  appearance  is  ex- 
ceedingly remarkable,  and  exactly  resembles  the  transparent  layers 
which  are  seen  in  agatose  pebbles,  surrounded  by  a  more  opaque  mass. 
The  surface  is  uniform,  even,  and  highly  polished,  and  continues, 
without  the  least  break,  from  one  tooth  to  another.  It  extends  at 
present  to  the  bicuspids,  is  perfectly  equal  on  both  sides,  and  when  the 
molars  are  closed,  the  opening,  by  this  loss  of  substance  in  front,  is 
observed  to  be  widest  in  the  centre,  diminishing  gradually  and  equally 
on  both  sides  to  the  last  bicuspids." 


330  DENTAL   PATHOLOGY,  THERAPEUTICS. 

CAUSES. 

The  same  cause  may  be  ascribed  for  this  affection  as  for  that  of  de- 
nuding, namely,  a  defect  of  structure,  which  renders  the  central  por- 
tions of  the  tooth  surface  susceptible  to  the  action  of  an  acid  contained 
in  the  mucus  ;  although  the  polished  condition  of  the  alveolar  surfaces 
would  appear  to  render  such  a  theory  somewhat  untenable.  Hence 
the  cause  of  chemical  abrasion  is  yet  doubtful,  although  mechanical 
abrasion  combined  with  the  chemical  action  may  account  for  the 
smooth  and  polished  surfaces  which  are  invariably  present. 

TREATMENT. 

If  the  tendency  to  an  acidulated  condition  of  the  raucous  secretions 
of  the  mouth  could  be  overcome  or  counteracted,  the  progress  of  this 
affection  of  the  teeth,  perhaps,  might  be  arrested.  But  the  permanent 
ciire  of  an  obscure  abnormal  condition  of  any  secretion  is  a  tedious, 
difficult,  and  often  impossible  thing.  It  may  require  h3'gienic  and  con- 
stitutional treatment,  such  as  comes  more  within  the  province  of  the 
family  physician  than  of  the  dentist.  But  we  know  of  no  treatment 
that  will  control  or  arrest  this  singular  disease. 


CHAPTER  XXII. 

MECHANICAL   ABRASION   OF   THE   TEETH. 

"TTTERE  it  true,  as  declared  by  Richerand,  that  the  loss  of  the  enamel 
'  '  occasioned  by  friction  is  repaired  by  a  new  growth,  it  would  never 
suffer  permanent  loss  from  mechanical  abrasion.  But  enamel  and  den- 
tine, once  formed,  pass  beyond  the  sphere  of  that  reparative  power 
found  in  other  bony  tissues  where  red  blood  circulates  freely.  New 
enamel  is  therefore  never  formed  after  the  eruption  of  the  tooth  ;  and 
new  dentine  only  upon  the  surface  of  the  lining  membrane,  which  is 
exceedingly  vascular. 

The  teeth  rarely  suffer  loss  of  substance  from  friction  when  the  incis- 
ors of  the  upper  jaw  shut  in  front  of  those  of  the  lower.  It  is  only 
when  the  former  fall  directly  upon  the  latter,  that  mechanical  abrasion 
of  the  cutting  edges  can  take  place,  and  when  this  happens,  they  some- 
times suffer  great  loss  of  substance.  The  crowns  of  these  teeth  are 
occasionally  worn  entirely  off,  while  those  of  the  molars  and  bicuspids 
are,  comparatively,  little  affected.  The  lateral  motions  of  the  jaw, 
being  in  these  cases  unrestricted — and  this  motion  being,  of  course, 


MECHANICAL   ABRASION   OF   THE   TEETH.  331 

greater  at  the  anterior  than  at  the  posterior  part  of  the  mouth — it 
neeessarily  happens  that  the  front  teeth  suffer  the  most  abrasion. 
Sometimes  all  the  teeth  are  worn  off  alike ;  at  other  times,  owing  to 
the  peculiar  manner  in  which  the  jaws  come  together,  the  abrasion  is 
confined  to  a  few. 

Mr.  Bell  believes  that  certain  kinds  of  diet  tend,  more  than  others, 
to  produce  abrasion  of  teeth ;  in  proof  of  which  he  tells  us  that  sailors 
who,  the  greater  portion  of  their  lives,  live  on  hard  biscuits,  have  only 
a  small  part  of  the  crowns  of  their  teeth  remaining.  But  the  antago- 
nism of  the  teeth  has  much  more  to  do  with  it  than  the  nature  of  the 
food  ;  though,  of  course,  when  they  do  not  strike  in  such  a  way  as  to 
wear  the  cutting  surfaces,  very  hard  or  gritty  articles  of  food  would 
make  the  abrasion  more  rapid. 

When  the  front  teeth  of  the  lower  jaw  strike  against  the  palatine 
surface  of  those  of  the  upper,  the  latter  are  sometimes  worn  away  more 
than  three-fourths,  and  in  some  instances  entirely  upon  the  gums.  We 
have  seen  the  teeth  of  some  individuals  so  much  abraded,  in  this  way, 
that  little  of  the  crown  remained,  except  the  enamel  on  the  anterior 
surface. 

The  wearing  away  of  the  crowns  of  the  teeth  would  expose  the  lining 
membrane,  were  it  not  that  Nature,  in  anticipation  of  the  event,  sets 
up  an  action  by  which  the  pulps  are  transformed  into  a  substance 
called  osteo-dentine,  which  is  analogous  in  structure  to  cementum.  By 
this  beautiful  operation  of  the  economy,  the  painful  consequences  that 
would  otherwise  result  are  wholly  prevented. 

TREATMENT. 

The  adaptation  of  caps  of  gold  or  other  metal,  or  gold  in  the  form 
of  contour  fillings,  to  the  cutting  edges  and  grinding  surfaces  worn 
away  by  mechanical  abrasion,  will  often  preserve  and  render  useful 
teeth  in  such  a  condition. 


CHAPTER  XXIII. 


FRACTURES   AND    OTHER   INJURIES   OF   THE   TEETH   FROM   MECHANI- 
CAL  VIOLENCE. 

THE  injuries  to  which  teeth  are  subject  from  mechanical  violence 
are  so  variable  in  their  character  and  results  as  to  render  a  de- 
tailed description  impossible.  The  same  amount  of  violence  inflicted 
upon  a  tooth  does  not  always  produce  the  same  effect.  The  nature  and 
extent  of  the  injury  will  depend  as  much  upon  the  physical  condition 


332  DENTAL  PATHOLOGY,  THERAPEUTICS. 

of  the  teeth,  the  state  of  the  constitutional  health,  and  the  suscepti- 
bility of  the  body  to  morbid  impressions,  as  upon  the  violence  of  the 
blow.  Thus,  a  blow  sufficiently  severe  to  loosen  a  tooth  might  not,  in 
one  case,  be  productive  of  any  permanent  bad  consequences ;  while  in 
another,  it  might  cause  the  death  of  the  organ  and  inflammation  of 
the  adjacent  parts,  as  well  as  necrosis  of  the  alveolus. 

A  tooth  of  compact  texture,  and  in  a  healthy  mouth,  may  be  deprived 
of  a  portion  of  its  substance  without  any  serious  injury ;  but  a  similar 
loss  of  substance  in  a  tooth  not  so  dense  in  structure  would  be  likely 
to  produce  inflammation  and  suppuration  of  the  lining  membrane, 
and  possibly  of  the  alveolo-dental  periosteum.  Hence,  in  order  to 
form  a  correct  opinion  of  the  result  of  injuries  of  this  sort,  we  must 
take  into  consideration  not  only  the  character  of  the  tooth  upon  which 
the  blow  has  been  inflicted,  but  also  the  state  of  the  mouth  and  the 
health  of  the  individual. 

If  the  tooth  is  not  loosened  in  its  cavity,  any  injury  resulting  from 
a  loss  of  a  small  portion  of  the  enamel,  or  even  of  the  dentine,  may 
be  prevented  by  smoothing  the  fractured  surface  with  a  file,  that  the 
juices  of  the  mouth  and  particles  of  extraneous  matter  may  not  be 
retained  in  contact  with  it.  But  if  the  tooth  is  loosened,  and  inflam- 
mation of  the  investing  membrane  has  supervened,  leeches  should  be 
applied  to  the  gums,  and  the  mouth  washed  several  times  a  day  with 
some  astringent  lotion,  until  the  inflammation  subsides.  For  more 
detailed  treatment,  the  reader  is  referred  to  the  chapter  on  periostitis. 

When  a  tooth  has  been  displaced  from  its  cavity  by  a  blow,  and  its 
vascular  connection  with  the  general  system  destroyed,  necrosis  must, 
as  an  almost  necessary  consequence,  be  the  result.  An  imperfect  union 
between  the  tooth  and  alveolus  may  sometimes  be  re-established  by  the 
efiusion  of  coagulable  lymph,  and  the  formation  of  an  imperfectly 
organized  membrane ;  but  the  tooth  will  ever  after,  from  the  slightest 
cold,  or  derangement  of  the  digestive  organs,  be  liable  to  become  sore 
to  the  touch,  and  in  most  cases  will  ultimately  assume  a  muddy  brown, 
unhealthy  appearance. 

The  author  has,  on  several  occasions,  replaced  teeth  that  had  been 
knocked  from  their  cavities ;  and  in  some  instances  the  operation  was 
attended  with  success.  The  subject  in  one  case  was  a  healthy  boy,  of 
about  thirteen  years  of  age,  who,  while  playing  bandy,  received  a 
blow  from  the  club  of  one  of  his  playmates,  which  knocked  the  left 
central  incisor  of  the  upper  jaw  entirely  out  of  its  cavity.  He  saw  the 
boy  about  fifteen  minutes  after  the  accident.  The  alveolus  was  filled 
with  coagulated  blood.  This  he  sponged  out,  and  after  having  bathed 
the  tooth  in  tepid  water,  carefully  and  accurately  replaced  it  in  its 
socket,  and  secured  it  there  by  silk  ligatures  attached  to  the  adjacent 


INJURIES  OF  TEETH  FROM  MECHANICAL  VIOLENCE.         333 

teetli.  On  the  following  day  the  gums  around  the  tooth  were  con- 
siderably inflamed,  to  reduce  which  inflammation  he  directed  an 
application  of  three  leeches  and  the  frequent  use  of  diluted  tincture 
of  myrrh  as  a  wash  for  the  mouth.  At  the  expiration  of  four  weeks 
the  tooth  became  firmly  fixed  in  its  socket,  but  from  the  eflTusion  of 
coagulable  lymph,  the  alveolar  membrane  was  thickened,  and  the 
tooth,  in  consequence,  protruded  somewhat.  A  slight  soreness,  on 
taking  cold,  has  ever  since  been  experienced. 

Dr.  Noyes,  of  Baltimore,  mentioned  to  the  author  a  case  of  a 
somewhat  similar  character.  The  subject  was  a  boy  about  ten 
years  of  age.  One  of  his  front  teeth  was  forced  from  its  socket 
by  a  fall.  It  was  replaced  'shortly  after,  and  in  a  few  weeks  became 
firm  in  its  alveolus.  Mr.  Bell  also  mentions  a  case  attended  with  a 
like  result. 

The  alveolar  processes  and  jaw  bones  are  sometimes  seriously  in- 
jured by  mechanical  violence.  In  1843,  the  author  was  requested  by 
the  late  Dr.  Baker,  of  Baltimore,  to  visit,  with  him,  a  lady  who,  by 
the  upsetting  of  a  stage,  had  her  face  severely  bruised  and  lacerated. 
All  that  portion  of  the  lower  jaw  which  contained  the  six  anterior 
teeth  was  splintered  off,  and  was  only  retained  in  the  mouth  by  the 
gums  and  integuments  with  which  it  was  connected.  The  wounds  of 
her  face  having  been  properly  dressed,  the  detached  portion  of  the 
jaw  was  carefully  adjusted  and  secured  by  a  ligature  passed  around 
the  front  teeth  and  first  molars,  and  by  a  bandage  on  the  outside, 
around  the  chin  and  back  part  of  the  head.  Her  mouth  was  washed 
five  or  six  times  a  day  with  diluted  tincture  of  myrrh.  The  third  day 
after  the  accident  Dr.  Baker  directed  the  loss  of  twelve  ounces  of 
blood ;  and  in  five  or  six  weeks,  with  no  other  treatment  than  the 
dressing  of  the  wounds,  she  perfectly  recovered. 

It  often  happens  that  the  crown  of  a  tooth  is  broken  off"  at  the  neck. 
We  have  known  the  crowns  of  four,  and  in  one  case  of  thirteen,  teeth 
to  be  fractured  by  a  single  blow.  The  subject  of  the  last  case  was  a 
fireman,  who,  in  1^535,  received  an  accidental  blow  on  his  mouth  from 
the  head  of  an  axe,  which  broke  off"  the  crowns  of  all  the  upper  and 
lower  incisors,  two  cuspids,  and  three  of  the  bicuspids  of  the  inferior 
maxilla.  The  subject  in  the  other  case  was  a  boy  about  twelve  years 
of  age,  who,  from  a  similar  accident,  occasioned  by  running  up  sud- 
denly behind  a  man  who  was  chopping  wood,  had  the  crowns  of  his 
upper  incisors  broken  ofi".  In  both  of  these  cases  the  inflammation 
which  supervened  was  so  great  as  to  render  the  removal  of  the  roots 
necessary.  The  crowns,  roots,  and  alveolar  processes  are  sometimes 
ground  to  pieces,  or  the  teeth  driven  into  the  very  substance  of  the 
jaw.     Mr.  Bell  says  he  once  found   a  central  incisor  so  completely 


334  DENTAL   PATHOLOGY,  THERAPEUTICS. 

forced  into  the  bone,  that  he  thought  it  to  be  the  remains  of  a  root ; 
but,  on  removing  it,  found  it  to  be  an  entire  tooth. 

When  the  crown  of  a  tooth  has  been  broken  off  by  a  blow,  and 
destructive  inflammation  results,  the  root  should  be  extracted.  When, 
however,  the  injury  has  not  been  sufiicient  to  cause  such  a  degree  of 
inflammation,  an  artificial  crown  may  be  engrafted  on  the  root ;  but  it 
is  very  necessary  that  the  inflammation  should  be  entirely  subdued 
previous  to  the  operation  of  pivoting.  If  the  tooth  is  to  be  replaced 
with  an  artificial  substitute  attached  to  a  plate,  the  root  should  be  first 
extracted.  In  some  cases,  however,  the  root  may  be  filled  and  be 
permitted  to  remain ;  but  the  practice  is  usually  a  bad  one.  The 
possibility  of  a  fractured  tooth  reuniting  was  formerly  doubted,  but 
Wedl,  in  his  "  Pathology  of  the  Teeth,"  refers  to  some  fifteen  cases  in 
which  union  took  place,  some  of  which  were  due  to  the  formation  of 
secondary  dentine,  and  others  to  that  of  cementum. 


CHAPTER   XXIV. 

CARIES   OF   THE   TEETH. 


rpHE  teeth  are  more  liable  to  be  attacked  "by  caries  than  by  any 
-L    other  disease,  and  this  will  now  claim  our  attention. 

Caries  of  a  tooth  is  the  chemical  decomposition  of  the  earthy  salts 
of  the  affected  part,  sometimes,  but  not  always,  accompanied  by  dis- 
organization of  the  animal  framework  of  this  portion  of  the  organ. 
There  is  no  affection  to  which  these  organs  are  liable  more  frequent  in 
its  occurrence,  or  fatal  in  its  tendency,  than  this.  It  is  often  so  insidi- 
ous in  its  attacks,  and  rapid  in  its  progress,  that  every  tooth  in  the 
mouth  is  involved  in  irreparable  ruin  before  even  its  existence  is  sus- 
pected. 

Its  presence  is  usually  first  indicated  by  an  ojiaque  or  dark  spot  on 
the  enamel ;  and,  if  this  be  removed,  the  subjacent  dentine  will  exhibit 
a  black,  dark-brown,  or  whitish  appearance.  It  usually  commences  on 
the  outer  surface  of  the  dentine  of  the  crown,  beneath  the  enamel,  at 
some  point  where  it  is  imperfect,  or  has  been  fractured  or  otherwise 
injured ;  from  thence  it  proceeds  toward  the  centre  of  the  tooth,  in- 
creasing in  circumference  until  it  reaches  the  pulp  cavity. 

If  the  diseased  part  is  of  a  soft  and  humid  character,  the  enamel, 
after  a  time,  usually  breaks  in,  disclosing  the  ravages  the  disease  has 
made  on  the  subjacent  dentine.     But  this  does  not  always  happen ;  the 


CARIES   OF   THE   TEETH. 


335 


form  of  the  tooth  sometimes  remains  nearly  perfect  until  its  whole 
interior  structure  is  destroyed. 

No  portion  of  the  crown  or  neck  of  a  tooth  is  exempt  from  this 
disease ;  yet  some  parts  are  more  liable  to  be  first  attacked  than  others ; 
as,  for  example,  the  depressions  iu  the  grinding  surfaces  of  the  molars 
and  bicuspids,  the  approximal  surfaces  of  all  the  teeth,  the  posterior 
or  palatine  surfaces  of  the  lateral  incisors,  and,  in  short,  wherever  an 
imperfection  of  the  enamel  exists. 

The  enamel  is  much  harder  than  the  dentine,  and  is  by  far  less  easily 
acted  on  by  the  causes  that  produce  caries.  It  is  sometimes,  however, 
the  first  to  be  attacked,  and  when  this  happens,  the  disease  develops 
itself  more  frequently  on  the  labial  or  buccal  surface,  near  the  gum, 
than  in  any  other  locality ;  often  commencing  at  a  single  point,  and  at 
other  times  at  a  number  of  points.  When  the  enamel  is  first  attacked, 
it  is  usually  called  erosion ;  but  as  this  tissue  does  not  contain  so  much 
animal  matter  as  the  subjacent  dentine,  the  diseased  part  is  often 
washed  away  by  the  saliva  of  the  mouth  ;  while  in  the  dentinal  part 
of  the  tooth,  it,  in  most  instances,  remains,  and  may  be  removed  in 
distinct  laminae,  after  the  earthy  salts  have  been  decomposed. 

In  very  hard  teeth,  the  decayed  part  is  of  a  firmer  consistence,  and 
of  a  darker  color  than  in  soft  teeth.  Sometimes  it  is  black ;  at  other 
times  of  a  dark  or  light  brown ;  and  at  other  times,  again,  it  is  nearly 
white.  As  a  general  rule,  the  softer  the  tooth,  the  lighter,  softer  and 
more  humid  the  caries.  The  color  of  the  decayed  part,  however,  may 
be,  and  doubtless  is,  iu  some  cases,  influenced  by  other  circumstances; 
perhaps  by  some  peculiar  modifications  of 
the  agents  concerned  in  the  production  of 
the  disease. 

Commencing  externally  beneath  the  en- 
amel, the  disease  proceeds,  as  before  stated, 
toward  the  centre  of  the  tooth,  destroying 
layer  after  layer,  until  it  reaches  the  lining 
membrane,  leaving  each  outer  stratum  softer 
and  of  darker  color  than  the  subjacent  one. 
The  dentinal  tubuli  become  less  distinct 
near  the  margin  of  the  carious  structure  than 
is  the  case  in  the  perfectly  normal  tissue  in 
proximity  with  the  pulp  chamber,  and,  ac- 
cording to  Mr.  John  Tomes,  has  a  zone-like 
form  (the  zone  of  Tomes),  which  he  regards 
as  a  consolidation  of  the  dentinal  tubuli,  an 
effort  on  the  part  of  nature  to  place  a  line 
of  demarcation  between  the  healthy  and  carious  structure. 


Fig.  104. 


*A  transparent  zone  of  dentine, 
removed  a  short  distance  from  and 
Burrounding  that  which  is  undergo- 
ing decomposition  consequent  upon 
caries. 


336  DEXTAL  PATHOLOGY,  THERAPEUTICS. 

Other  writers  consider  this  zone  of  transparency  to  be  the  result  of 
diseased  action  causing  a  complete  exclusion  of  air  from  the  tubuli, 
thus  rendering  them  invisible  when  viewed  by  transmitted  light. 

The  terms  deep-seated,  superficial,  external  and  internal,  shnple  and 
complicated,  have  been  applied  to  the  disease.  These  distinctions 
only  designate  different  stages  of  the  same  affection.  By  complicated 
decay  is  meant  caries  which  has  penetrated  to  the  pulp  cavity  of  the 
tooth,  accompanied  by  inflammation  and  suppuration  of  the  lining 
membrane,  and  the  death  of  the  organ.  The  lining  membrane,  how- 
ever, is  not  always  inflamed  by  exposure,  nor  is  inflammation  in- 
variably followed  by  suppuration. 

The  roots  of  the  teeth  frequently  remain  firm  in  their  sockets  for 
years  after  the  crowns  and  necks  have  been  destroyed,  showing  that 
they  are  less  liable  to  decay  than  the  crowns  ;  but  nature,  after  the 
destruction  of  the  last,  as  if  conscious  that  the  former  are  of  no  further 
use,  exerts  herself  to  expel  them  from  the  system,  which  is  effected  by 
the  gradual  wasting  and  filling  up  of  their  sockets.  After  this  opera- 
tion of  the  economy  has  been  accomplished,  they  are  frequently  re- 
tained in  the  mouth  for  months,  and  even  for  years,  by  their  periosteal 
connection  with  the  gums.  The  effort  of  nature  is  confined  more  to 
the  back  than  to  the  front  teeth ;  it  often  happens  that  the  last  remain, 
after  the  destruction  of  their  crowns,  for  many  years,  and  sometimes 
without  much  apparent  injury  to  the  parts  within  which  they  are  con- 
tained. 

DIFFERENCES   IN   THE    LIABILITY    OF     DIFFERENT   TEETH   TO    DECAY. 

Having  explained  at  some  length,  in  a  preceding  part  of  this  work, 
the  manner  in  which  the  physical  condition  of  the  teeth  is  influenced, 
it  will  not  now  be  necessary  to  dwell  upon  this  portion  of  the  subject. 
It  will  only  be  requisite  to  state,  therefore,  that  teeth  which  are  well- 
formed,  well  arranged,  and  of  a  firm  texture,  seldom  decay,  and  when 
they  are  attacked,  the  progress  of  the  disease  is  not  rapid  ;  whereas, 
those  that  are  imperfect  in  their  formation,  and  of  a  soft  texture,  are 
more  susceptible  to  the  action  of  the  causes  which  produce  it ;  and 
when  assailed,  if  the  progress  of  the  affection  is  not  arrested  by  art, 
they  usually  fall  speedy  victims  to  its  ravages.  Just  in  proportion  as 
the  dentinal  structure  of  the  teeth  is  hard  or  soft,  the  shape  of  the  or- 
gans perfect  or  imperfect,  their  arrangement  regular  or  irregular,  is 
their  liability  to  caries  diminished  or  increased. 

The  density,  shape  and  arrangement  of  the  teeth  are  influenced  by 
the  state  of  the  general  health,  and  that  of  the  mouth  at  the  time  of 
their  dentiuification.  If,  at  this  period,  all  the  functions  of  the  body 
are  healthily  performed,  these  organs  will  be  compact  in  their  struc- 


CARIES    OF   THE   TEETPI.  337 

ture,  perfect  in  their  shape,  and  usually  regular  in  their  arrangement. 
That  the  teeth  should  be  thus  influenced  will  not  appear  strange,  when 
we  consider,  as  Richeraud  remarks,  "  that  there  exists  amongst  all  the 
parts  of  the  living  body  intimate  relations,  all  of  which  correspond  to 
each  other,  and  carry  on  a  reciprocal  intercourse  of  sensations  and 
affections.  Hence,  if  there  is  a  morbid  action  in  one  part,  other  parts 
sympathize  with  it,  rallying,  as  if  sensible  of  the  mutual  dependence 
existing  between  them,  all  their  energies  to  rescue  their  neighbor  from 
the  power  of  disease." 

Increased  action  in  one  portion  of  the  system  is  generally  followed 
by  diminished  action  in  some  other  part ;  thus,  for  example,  gastritis 
may  be  produced  by  constipation  of  the  bowels ;  puerperal  fever  by 
diminished  action  in  the  heart,  with  an  increased  action  in  the  uterus, 
etc.  Hence,  we  may  conclude,  that  if  the  body,  at  an  early  age,  be 
morbidly  excited,  its  functions  will  be  languidly  performed,  the  pro- 
cess of  assimilation  checked,  the  regular  and  healthy  supply  of  earthy 
matter  in  the  bones  interrupted,  and,  consequently,  that  the  teeth 
which  are  then  formed  will  be  defective.  Other  parts  of  the  body,  in 
which  constant  changes  are  going  on,  if  thus  affected  at  these  early 
periods,  may  afterwards  recover  their  healthful  vigor;  but  if  the  teeth 
are  badly  formed,  they  must  ever,  because  of  their  low  degree  of  vas- 
cularity, continue  so ;  hence  they  will  be  more  liable  to  decay  than 
when  dentinified  under  other  and  more  favorable  circumstances. 

Capillary  blood  vessels  form  a  large  part  of  every  organ,  the  charac- 
teristic tissue  of  each  being  strictly  extra-vascular  (literally,  outside  of 
the  vessels).  Where  the  blood  vessels  are  most  abundant,  as  in  the 
nervous  and  muscular  structures,  growth  and  change  take  place 
rapidly  and  constantly  ;  since  almost  every  particle  of  the  extra- 
vascular  or  interstitial  tissue  is  in  contact  with  the  circulating  fluid, 
the  function  of  which  is  to  supply  material  for  growth  and  carry  off" 
waste  matter.  Hence  such  organs  have  great  recuperative  power,  and 
are  modified  by  the  varying  conditions  of  the  body.  But  the  den- 
tine and  enamel  of  the  teeth  are  vascular  only  during  the  period 
of  development. 

These  structures,  once  formed,  pass  beyond  the  reach  of  the  capil- 
laries, except  the  layer  of  dentine  in  contact  with  the  dental  pulp. 
Hence  the  dental  pulp  may  deposit  new  bone  as  a  barrier  against  caries ; 
but  the  carious  dentine  itself  is  incapable  of  self-restoration. 

"  That  the  teeth  acquire  this  disposition  to  decay,"  says  Mr.  Fox, 
"from  some  want  of  healthy  action  during  their  formation,  seems  to  be 
proved  by  the  common  observation,  that  they  become  decayed  in  pairs  ; 
that  is,  those  which  are  formed  at  the  same  time,  being  in  a  similar 
state  of  imperfection,  have  not  the  power  to  resist  the  causes  of  the 
22 


338  DENTAL  PATHOLOGY,  THERAPEUTICS. 

disease,  and  therefore,  at  nearly  about  the  same  poriod  of  time  exhibit 
signs  of  decay ;  while  those  which  have  been  formed  at  another  time, 
when  a  more  healthy  action  has  existed,  have  remained  perfectly  sound 
to  the  end  of  life." 

Most  writers  are  of  opinion  that  the  power  of  the  teeth  to  resist  the 
various  causes  of  decay  is  sometimes  weakened  by  a  change  brought 
about  in  their  physical  condition  through  the  agency  of  certain  remote 
causes,  such  as  the  profuse  administration  of  mercury,  the  existence  of 
fevers  and  all  severe  constitutional  disorders. 

Severe  constitutional  disorders,  and  the  administration  of  certain 
kinds  of  medicine,  may  not  act  directly  on  the  teeth,  by  altering  their 
physical  condition,  and  thus  rendering  them  more  susceptible  to  the 
action  of  corrosive  agents  ;  but  they  are  indirectly  affected  in  propor- 
tion as  the  secretions  of  the  mouth  are  vitiated  and  their  corrosive 
properties  increased. 

The  following  considerations  establish,  to  our  mind,  the  truth  of 
what  we  have  just  stated.  Artificial  teeth  of  bone  or  ivory  decay 
more  rapidly  after  the  profuse  administration  of  medicine,  or  during 
the  existence  of  any  disease  that  tends  to  vitiate  the  secretions  of  the 
mouth,  than  at  other  times.  Furthermore,  teeth  of  so  dense  a  texture 
as  to  be  capable  of  resisting  the  action  of  the  acidulated  buccal  fluids 
are  not  affected  by  constitutional  disease;  yet  they  are  just  as  liable  as 
those  of  a  spongy  texture,  to  any  structural  disease  communicated  from 
the  general  system. 

The  following  is  the  result  of  our  own  observations:  the  gums  and 
alveolar  processes  are  sometimes  destroyed  by  the  use  of  mercury,  so 
that  all  the  teeth  loosen  and  drop  out,  without  being  affected  by  caries. 
The  teeth  of  persons  in  whom  a  mercurial  diathesis  has  been  a  long 
time  kept  up,  or  who  have  been  for  years  suffering  from  dyspepsia, 
phthisis,  fevers,  or  other  severe  constitutional  disorders,  often  continue 
perfectly  sound  ;  while  other  teeth,  under  similar  circumstances,  fre- 
quently decay.  Now,  all  this  goes  to  prove,  not  that  changes  are  ef- 
fected in  the  structural  condition  of  the  teeth,  whereby  their  predispo- 
sition to  decay  is  increased,  but  that  there  are  differences  in  the  capa- 
bilities of  different  teeth  to  resist  the  action  of  the  secretions  of  the 
mouth,  made  acrid  by  the  affections  just  enumerated. 

The  author  has  noted  the  effects  of  mercury  and  of  other  medicines, 
as  well  as  of  constitutional  diseases  of  the  severest  and  most  jDrotracted 
kinds,  and  has  always  observed  that — occurring  a/fer  the  development 
of  the  teeth — it  was  only  as  they  impaired  the  healthy  qualities  of  the 
fluids  of  the  mouth  that  they  affected  these  organs.  In  fact,  their 
density,  their  exposed  situation,  their  functions,  all  Avould  seem  to  in- 
dicate that  such  changes  as  take  place  in  other  parts  of  the  body  are 


CARIES   OF   THE   TEETH.  339 

not  only  unnecessary,  but  many  of  them  are  impossible,  and  designedly 
so,  that  they  may  more  fully  answer  their  purpose. 

Dr.  Good  says  "  that  caries  of  the  teeth  does  not  appear  to  be  a  dis- 
ease of  any  particular  age  or  temperament,  or  state  of  health."  It  is 
true  it  is  not  a  disease  of  any  particular  state  of  health,  further  than 
that  certain  constitutional  affections  exert  a  deleterious  influence  upon 
the  secretions  of  the  mouth,  and  thus  become  indirect  causes  of  decay 
of  these  organs.  That  it  is  not  a  disease  of  any  particular  age  seems 
to  contradict  common  experience,  for  it  eomparativeli/  seldom  happens 
that  caries  appears  after  the  age  of  forty.  The  reason  of  which  is 
obvious.  Teeth  of  a  loose  texture,  or  otherwise  imperfect,  cannot  re- 
sist the  action  of  the  causes  of  decay  to  which  all  teeth  are,  up  to  this 
period  of  life,  more  or  less  exposed ;  while  those  which  from  their 
greater  density  remain  unaffected  thus  long,  are  generally  enabled,  by 
the  increased  solidity  they  gradually  acquire,  to  resist  them  through 
life.  Teeth  sometimes,  though  rarely,  decay  at  fifty,  or  even  at  a  later 
period ;  but  caries  of  the  teeth,  generally,  may  be  said  to  be  confined 
to  youth  and  middle  age. 

The  formation,  arrangement,  and  physical  condition  of  the  teeth 
are  sometimes  influenced  by  hereditary  diathesis,  affecting  the  parts 
concerned  in  their  production,  or  the  general  system.  That  a  morbid 
condition  of  the  system,  on  the  part  of  either  parent,  often  predisposes 
their  progeny  to  like  affections,  is  an  axiom  fully  recognized  in  path- 
ologA'',  and  a  fact  of  which  we  have  many  fearful  proofs. 

That  there  is  an  hereditary  tendency  in  the  teeth  to  decay,  cannot, 
we  think,  be  denied.  But  we  believe  it  to  be  the  result  of  the  trans- 
mission of  a  similarity  of  action  in  the  parts  concerned  in  the  produc- 
tion of  these  organs ;  so  that  the  teeth  of  the  child  are,  in  form  and 
structure,  like  those  of  the  parent  whom  it  most  resembles,  and  from 
whom  it  has  inherited  the  diathesis.  The  teeth  of  the  child,  if  shaped 
like  those  of  the  parent,  possessing  a  like  degree  of  density,  and  simi- 
larly arranged,  are  equally  liable  to  disease;  when  exposed  to  the  action 
of  the  same  causes,  they  are  affected  in  like  manner,  and,  usually,  at 
about  the  same  period  of  life.  Such  being  the  fact,  is  it  unreasonable 
to  conclude  that  judicious  early  attention  may  so  influence  the  forma- 
tion and  arrangement  of  the  teeth  that  their  liability  to  disease  may 
be  diminished?  Medicinal  remedies  and  sickness  have  a  powerful 
influence  upon  the  dental  tissues ;  first,  through  hereditary  transmission 
of  an  impaired  constitution  ;  secondly,  by  their  action  upon  the  process 
of  development,  if  given  while  the  teeth  are  being  formed.  It  is,  then, 
to  the  differences  in  the  physical  condition  and  manner  of  arrangement 
of  these  organs — whether  in  different  individuals  or  in  the  same  mouth 
— that  the  differences  in  their  liability  to  decay  is  attributable. 


340  DENTAL  PATHOLOGY,  THERAPEUTICS. 

Dr.  John  Allen  remarks :  "  The  nutritious  substances  in  the  food 
that  we  take  are  intended  to  build  up  all  parts  of  the  system — the 
hard  tissues  as  well  as  the  soft  tissues.  Of  the  food  intended  to  build 
up  these  organisms,  certain  portions  make  bone  and  teeth.  Now  the 
particles  of  matter  are  deposited  atom  by  atom,  and  the  system  is 
gradually  built  up.  When  we  take  food  into  the  system,  it  is  con- 
verted into  blood.  This  blood  is  conveyed  through  all  parts  in  little 
corpuscles,  which  are  freighted  with  the  proper  constituents  to  sustain 
and  build  up  these  organisms.  These  little  corpuscles  convey  such 
constituents  as  are  necessary  for  the  production  of  bone,  teeth,  flesh, 
and  the  fat,  and  these  various  substances  are  deposited  just  where  they 
should  be.  Now  it  is  essentially  necessary  that  we  have  these  little 
vesicles  freighted  with  the  proper  constituents,  and  duly  freighted. 
How  shall  we  know  this?  By  taking  the  food  just  in  the  proportion 
that  it  is  provided  for  us  by  our  Creator,  and  as  it  comes  from  nature's 
laboratory. 

"  Now  we  take  this  ground  from  the  fact  that,  as  a  nation,  we  have 
worse  teeth  than  any  other  on  the  earth.  Now  why  is  this  ?  Simply 
because  we  change  the  proportions  of  these  various  constituents  that 
our  Creator  has  provided  for  us,  by  separating  away  what  has  been 
put  there  for  the  building  up  of  the  hard  tissues, 

"  To  prove  this,  let  us  look  to  other  nations.  They  that  do  not  change 
the  proportions  of  the  various  constituents  that  enter  into  their  bodies 
do  not  have  decayed  teeth. 

"  There  is  a  constant  change  going  on,  and  particles  of  matter  are 
deposited  atom  by  atom,  and  the  system  kept  fully  charged  with  the 
mineral  elements  of  which  these  structures  are  built  up.  When  you 
look  at  nations  that  do  not  change  the  proportions,  you  see  no  decayed 
teeth,  and  the  history  of  these  nations  proves  that  their  teeth  are  sound 
and  beautiful  to  old  age.  What  is  the  condition  in  our  country  ?  We 
do  change  these  proportions.  We  do  ignore  the  mineral  elements  pro- 
vided for  us,  and  we  do  have  decayed  teeth.  We  find  that  there  are 
over  twenty  millions  of  teeth  swept  from  our  population  every*^ear. 
We  do  not  take  the  material  into  our  system  that  carries  back,  atom 
by  atom,  and  keeps  the  hard  tissues  built  up  until  the  old  particles 
pass  away.  The  old  particles  pass  away  after  they  have  served  their 
purpose,  and  new  ones  then  take  their  places. 

"  It  is  estimated  that  every  child  uses  half  a  barrel  of  flour  every 
year ;  and  it  is  estimated  that  there  are  forty  pounds  of  the  bone-form- 
ing material  thrown  out  from  every  barrel  that  we  use.  The  child 
takes  its  food  on  fine  flour,  and  is  deprived  of  twenty  pounds  in  a  year 
of  this  mineral  element,  which  should  be  taken  into  the  system  in  order 
to  make  those  hard,  flinty  substances  that  our  Creator  intended.    Now, 


CARIES   OF   THE   TEETH.  341 

by  the  time  that  child  is  twenty  years  of  age,  it  has  been  deprived  of 
four  hundred  pounds  of  the  elements  which  should  have  been  taken 
into  the  system,  and  would  have  kept  it  charged  sufficiently  to  have 
preserved  these  substances  hard  and  flinty,  as  they  should  be. 

*'  We  sweep  from  our  American  population  over  twenty  millions  of 
teeth  every  year,  and  this  should  prove  the  theory  that  our  tissues  do 
undergo  a  change,  and  that,  particle  by  particle,  they  pass  away.  As 
it  is  now,  the  teeth  are  becoming  worse  and  worse  every  year ;  and  not 
only  this,  but  it  becomes  hereditary,  and  is  transmitted  from  parent  to 
child." 

CAUSES   OF   DENTAL   CARIES. 

Predisposing  Causes. — The  causes  of  dental  caries  are  divided  into 
predisposing  and  exciting ;  among  the  former  may  be  enumerated  a 
defective  constitution,  either  innate  in  the  child  as  derived  from  the 
parent,  or  acquired  from  accidental  influences  to  which  the  child  has 
been  exposed.  Any  condition  of  the  system  that  will  interfere  with 
the  proper  elimination  and  application  of  the  materials  necessary  for  the 
formation  of  perfect  structures  may  have  a  deleterious  influence  upon 
the  teeth.  Hereditary  defects  are  quite  common,  the  teeth  of  the  child 
exhibiting  the  peculiarities  of  those  of  the  parents.  Impaired  or  di- 
minished vitality  from  constitutional  or  local  causes  is  also  a  predis- 
posing cause  of  dental  caries.  Febrile  conditions  not  only  impair  or 
diminish  vitality,  but  change  the  nature  of  the  fluids  of  the  oral  cavity 
to  such  a  degree  as  to  cause  them  to  act  upon  the  teeth  very  injuriously. 
Dr.  George  Watt  remarks :  "  That  all  diseases  tend  to  weaken  the  den- 
tal organs,  and  thus  are  predisposing  causes  of  decay.  The  most  viru- 
lent are  the  eruptive  fevey-s,  such  as  typhus,  typhoid  and  scarlet  fevers, 
measles,  smallpox,  erysipelas,  etc.  These  fevers,  and  perhaps  all  dis- 
eases, predispose  to  decay  in  two  ways.  Weakening  the  entire  consti- 
tution, they  correspondingly  impair  the  vitality  of  the  teeth,  and  thus 
they  have  less  power  to  resist  the  encroachments  of  the  exciting  causes 
of  decay.  And  further,  they  deprave  the  secretions  of  the  salivary 
glands  and  the  oral  cavity,  rendering  them  liable  to  such  decomposition 
as  will  result  in  the  formation  of  exciting  causes." 

The  same  author  also  remarks :  "  That  the  condition  of  the  teeth  is 
influenced  by  heredity,  no  observing  dentist  can  doubt.  We  have  seen 
a  family  in  which  its  female  members,  for  four  generations,  lacked  the 
left  upper  lateral  incisor.  Sometimes  one  parent  has  good  teeth,  and 
good  dental  organs  pertain  to  the  family  history,  and  the  case  with  the 
other  pareut  is  just  the  reverse;  we  see  children  not  usually  having 
dental  organs  of  an  average  between  the  two  parents,  but  some  of  them 
copying  one  parent  and  some  the  other.  The  constitution  of  the  pa- 
rents, and  especially  that  of  the  mother,  may  be  unable  to  impart  due 


342  DENTAL   PATHOLOGY,  THERAPEUTICS. 

vigor,  or  proper  materials  in  requisite  quantities,  to  the  process  of  de- 
veloping the  teeth.  From  some  cause,  hereditary  or  otherwise,  there 
may  be  a  lack  of  lime  salts  in  the  system,  or  a  lack  of  physiological 
ability  to  appropriate  them  and  build  them  in  properly  with  the  or- 
ganic matter  of  the  teeth.  Another  condition  may  show  the  very  best 
formed  teeth,  while  the  alveolar  processes,  periosteum  and  mucous 
membrane  may  be  defective.  A  defective  periosteum  cannot  give 
efficient  nutrition;  deficient  development  of  the  alveoli  results  in 
ineffectual  support ;  while  if  anything  is  wrong  with  the  mucous  mem- 
brane we  may  have  to  contend  with  defective  or  depraved  secretions." 
Dyspepsia  afibrds  an  example  of  both  a  predisposing  and  an  ex- 
citing cause  of  caries,  as  its  effect  is  to  generate  an  acid  in  the  stomach 
which,  by  eructation,  is  brought  into  direct  contact  with  the  teeth. 
Malaria  is  a  predisposing  cause  of  dental  caries,  on  account  of  the 
unfavorable  conditions  it  induces;  also  such  medicinal  agents  as  vitiate 
the  oral  fluids  and  irritate  the  mucous  membrane  and  periosteum,  and 
interfere  with  the  functions  of  the  mucous  follicles  and  salivary  glands — 
mercury,  for  example ;  also  salivary  calculus,  by  its  irritating  effects 
upon  the  soft  tissues  in  connection  with  the  teeth,  and  its  influence 
upon  the  oral  secretions;  also  want  of  exercise,  which  affects  the 
stability  of  .the  teeth,  and  causes  absorption  of  the  alveoli ;  also  want 
of  cleanliness,  which  may  be  regarded  as  one  of  the  most  common  of 
the  predisposing  causes  of  dental  caries  ;  also  artificial  teeth  improperly 
inserted  or  composed  of  bad  materials ;  also  improper  dental  operations, 
both  as  regards  manner  and  time ;  also  diseased  teeth  and  roots  which 
are  productive  of  irritation  to  the  periosteum  and  gums ;  also  sudden 
changes  of  temperature,  which  may  cause  an  exalted  sensibility  of  the 
dentine,  diminish  the  vitality  of  the  teeth,  or  produce  checks  in  the 
enamel  of  frail  teeth. 

The  fissures  and  grooves  on  the  crowns  of  the  molars  and  bicuspids 
are  ascribed  by  some  to  an  arrest  of  development,  a  failure  of  the 
enamel  covering  in  its  formation  from  the  cusps  toward  the  centre  of 
the  crown  to  come  together  and  coalesce.  Others,  however,  ascribe 
these  defective  places  to  be  due  to  a  rupture  of  the  enamel  organ  at 
these  points — a  separation  of  the  ameloblastic  layer,  thus  separating 
the  enamel  rods  and  forming  a  fissure ;  such  fissures  being  more  common 
in  teeth  with  prominent  cusps. 

Exciting  or  Immediate  Causes. — The  exciting  or  immediate  cause  of 
dental  caries  is  conceded  to  be  the  action  of  agents  chemically 
disintegrating  the  hard  structures  of  the  teeth,  and  which  have  their 
source  in  the  vitiated  secretions  of  the  mouth,  abnormal  secretions  from 
the  stomach,  the  saliva,  the  mucus,  and  the  decomposition  of  aliimal 
and  vegetable  substances.     Fauchard,  Auzebe,  Bourdet,  and   other 


CARIES   OF   THE   TEETH. 


343 


Fig.  105. 


French  writers  of  the  eighteenth  century,  expressed  the  belief  that 
dental  caries  is,  for  the  most  part,  the  result  of  the  action  of  chemical 
agents ;  and  the  existence  of  an  acid  in  the  mouth  capable  of  decompo- 
sing the  teeth  was  conclusively  proven  by  Dr.  S.  K.  Mitchell,  in  1796. 
The  theory  that  the  decay  of  the  teeth  is  the  result  of  the  action  of 
external  agents  was  first  distinctly  suggested  to  the  dental  profession 
of  the  United  States,  about  the  year  1821,  by  Drs.  L.  S.  and  Eleazer 
Parmly,  The  late  Professor  Westcott,  by  a  series  of  experiments  made 
in  1843,  fouud  that  "  acetic  and  citric  acids  so  corroded  the  enamel  in 
forty-eight  hours,  that  much  of  it  was  easily  removed  with  the  finger 
nail,  and  malic  acid  or  the  acid  of  apples,  in  its  concentrated  state,  also 
acts  promptly  upon  the  teeth."  Dr.  W.  D.  Miller,  an  American  dentist 
practicing  in  Berlin,  deserves  great  credit  for  many  careful  investiga- 
tions made  to  determine  the  cause  of  dental  caries.  He  has  lately 
given  the  results  of  over  three  hundred  experiments,  and  has  cultivated 
bacteria  in  order  to  determine  the  nature  of  a  new  fungus  which  is 
always  found  in  the  mouth  and  in  carious  dentine,  and  which  is  always 
said  to  be  accompanied  by  a  strong  acid.  Dr.  Miller  maintains  that 
caries  are  caused  either  by  the  casual  intro- 
duction of  strong  acids  into  the  mouth,  or  by  the 
weaker  acids  formed  by  the  fermentation  of  fari- 
naceous or  saccharine  particles  of  food.  After 
the  destruction  of  the  enamel,  the  process  of 
disintegration  attacks  the  organic  matter,  and 
first  of  all  the  micro-organism,  which  causes 
an  endless  variety  of  changes  in  the  dentine, 
until  finally  it  presents  the  appearance  of  a 
mass  of  decomposed  matter  intersected  in  every 
direction  with  fungi.  Dr.  Miller  asserts  that 
he  has  been  convinced  by  an  examination 
of  several  hundreds  of  specimens,  that  after 
decalcification  has  taken  place,  the  only  change 
of  any  importance  which  occurs  is  produced  by 
micro-organisms.  And  he  further  says  that  he 
sees  "  the  need  of  little  or  nothing  more  than 
organic  acids  and  fungi  to  account  for  all  the 
phenomena  of  dental  caries."  "  Give  me  these 
two  factors  and  I  can  produce  caries  which  will 
deceive  the  most  experienced  operators  and 
raicroscopists." 

Dr.  Miller  sums  up  in  the  following  propositions  the  results  of  his 
investigations  on  the  subject  of  dental  caries : — 

First.     The  contact  of  saliva  with  amylaceous  or  saccharine  food 


Longitudinal  section  of  a  cari- 
ous bicuspid. 


344  DEXTAL   PATHOLOGY,  THERAPEUTICS. 

(not  to  speak  of  nitrogenous  food),  or  a  solution  of  sugar  or  starch  in 
saliva,  kept  at  body  temperature,  invariably  gives  rise  in  four  or  five 
hours  to  a  strong  acid  reaction,  due  to  the  generation  of  an  organic 
acid. 

Second.  There  must  consequently  be  in  the  human  mouth  a  con- 
stant though  variable  generation  of  acid,  because  of  the  impossibility 
of  keeping  the  mouth  perfectly  free  from  food  and  from  solutions  of 
amyloids  in  saliva,  which  penetrate  cracks,  pits  and  fissures,  or  are 
held  by  capillary  attraction  between  the  surfaces  of  teeth  in  contact, 
and  there  become  acid  by  fermentation. 

Third.  The  degree  of  acidity  depends  somewhat  upon  the  length 
of  time  which  has  elapsed  since  partaking  of  food,  and  will  be  found 
greatest  on  rising  in  the  morning. 

Fourth.  A  cavity  of  decay  in  which  saccharine  or  amylaceous  food 
has  remained  for  some  hours  must,  and  will  be  found,  always  and 
without  exception,  to  have  an  acid  reaction. 

Fifth.  The  extent  to  which  any  tooth  suffers  from  the  action  of  the 
acid  depends  upon  its  density  and  structure,  but  more  particularly 
upon  the  perfection  of  the  enamel  and  the  protection  of  the  neck  of 
the  tooth  by  healthy  gums.  What  we  might  call  the  perfect  tooth 
would  resist  indefinitely  the  same  acid  to  which  a  tooth  of  opposite 
character  would  succumb  in  a  few  wrecks. 

Sixth.  An  occasional  possible  absence  of  an  acid  reaction  in  a 
cavity  of  decay  is  no  indication  that  acid  has  not  participated  in  the 
production  of  the  cavity.  Little  or  no  value  can  be  attached  to  tests 
of  the  saliva  alone. 

Seventh.  Any  general  or  special  disorder  or  condition  of  the  system 
which  results  in  the  withdrawal  of  lime  salts  from  a  tooth,  or  in  a 
lowering  of  its  density,  or  in  a  weakening  of  the  chemical  union 
between  the  organic  and  inorganic  matter  of  the  tooth,  renders  it  more 
liable  to  decay. 

Eighth.  Strong  acid  and  corroding  substances  brought  but  mo- 
mentarily into  the  human  mouth,  may  give  rise  to  lesions  of  the 
enamel  at  points  where  the  ordinary  agents  alone  could  never  have 
begun. 

Ninth.  All  the  microscopical  appearances  and  characteristics  of 
caries  may  be  produced  with  the  greatest  exactness  out  of  the  mouth, 
simply  by  subjecting  teeth  to  those  acid  mixtures  which  are  constantly 
to  be  found  in  the  mouth. 

Tenth.  The  superficial  layers  of  carious  dentine  undergo  an  almost 
if  not  absolutely  complete  decalcification,  which  decreases  as  we  ap- 
proach the  normal  dentine.  The  same  is  true  of  dentine  decalcified 
in  saliva  and  bread. 


CARIES   OF   THE   TEETH.  345 

Eleventh.  The  destruction  of  the  organic  constituents  follows  (not 
precedes)  the  decalcification,  and  is  evidently,  for  the  most  part,  to  be 
ascribed  to  the  action  of  fungi. 

Twelfth.  The  fungi  found  in  the  human  mouth  do  not  participate 
directly  in  the  process  of  decalcification.  The  exact  part  which  they 
perform  in  the  production  of  an  acid  reaction  requires  further  in- 
vestigation. 

Thirteenth.  The  fungi  produce  the  most  manifold  anatomical  changes 
in  the  softened  dentine,  resulting  in  the  complete  obliteration  of  the 
structure  and  final  disappearance  of  the  tissue  in  a  mass  of  debris  and 
fungi. 

Fourteenth.  The  invasion  of  the  micro-organisms  is  always  preceded 
by  the  extraction  of  the  lime  salts. 

Fifteenth.  The  destruction  of  the  tissue  remaining  after  decalcifica- 
tion is  efiected  almost  wholly  by  fungi  alone. 

Sixteenth.  Inflammation  can  hardly  be  looked  upon  as  a  very 
important  factor  in  caries  of  the  teeth. 

Seventeenth.  Caries  of  the  enamel  is  purely  chemical,  the  decalcifica- 
tion resulting  at  once  in  the  complete  dissolution  of  the  tissue. 

Eighteenth.  Caries  of  cement  runs  a  course  analogous  to  caries  of 
dentine,  a  softening  of  the  tissues  by  acids,  and  following  this  its 
destruction  by  fungi ;  a  slight  inflammatory  action  on  the  part  of  the 
living  matter  in  the  corpuscles,  is  not  to  be  excluded. 

Dr.  George  Watt,  in  his  "Chemical  Essays"  on  "Caries  of  the 
Teeth,"  remarks :  "  It  is  evident  that  the  acids  do  not  all  act  alike  on 
the  teeth.  Indeed,  some  exert  no  influence  whatever  on  them,  while 
others  act  with  great  energy  on  each  and  all  of  their  constituents." 
In  his  notice  of  the  agents  which  ordinarily  act  chemically  on  the 
teeth,  producing  caries  and  chemical  abrasion,  he  accounts  for  the 
presence  of  certain  acids  in  the  mouth  as  follows:  "Oxygen  and  nitro- 
gen uniting  in  the  mouth,  in  whatever  proportions,  nitric  add  must  be 
the  ultimate  result,  as  air  and  moisture  the  only  agents  necessary  in 
the  transformation,  are  here  always  present.  Mucus  and  particles  of 
nitrogenous  food  lodged  about  the  teeth  undergo  decomposition,  and 
yield  nitrogen  to  the  oxygen  of  the  atmosphere,  or  of  the  fluids  of  the 
mouth.  Organic  nitrogenous  bodies  contain  hydrogen  and  oxygen,  as 
well  as  nitrogen  ;  consequently  by  their  decomposition  these  elements 
are  all  liberated.  The  mutual  affinities  of  hydrogen  and  nitrogen  take 
precedence,  and  the  result  is  the  formation  of  ammonia,  NII3 ;  ammonia 
exposed  to  the  action  of  oxygen  is  always  decomposed ;  oxide  of  nitro- 
gen is  formed,  and  nitric  acid  is  the  result."  If  buccal  mucus  as  well 
as  particles  of  nitrogenous  food  remain  around,  upon  and  between  the 
teeth,  till  decomposition  is  efiected,  the  white  variety  of  caries  is  pro- 


346  DENTAL  PATHOLOGY,  THERAPEUTIC-S. 

duced.  Nitric  acid  is  also  sometimes  formed  in  the  mouth  by  the 
agency  of  galvanic  action,  which  may  be  generated  by  two  metals 
placed  in  the  mouth  in  close  proximity  to  each  other,  and  the  fluids  of 
the  mouth  acting  on  one  of  them.  And  if  they  are  so  situated  that 
the  mucous  membrane  forms  a  connecting  conductor,  by  being  in 
contact  with  both,  a  current  may  be  established  sufficient  to  decom- 
pose any  of  the  binary  compounds  contained  in  these  fluids.  The 
liberated  nitrogen,  hydrogen  and  oxygen,  will  form  ammonia,  and  tlien 
nitric  acid.  But  galvanic  action  in  the  mouth  is  more  likely  to  de- 
velop hydrochloric  than  nitric  acid.  Some  writers;  however,  contend 
that  nitric  acid  is  never  formed  in  the  mouth,  for  the  reason  that  they 
have  not  found  it  present  in  a  free  state,  because  in  such  a  state  its 
effects  would  not  be  confined  to  carious  tooth  structure.  The  advo- 
cates of  its  presence  in  the  mouth  contend,  on  the  other  hand,  that  it 
combines  atom  by  atom,  as  rapidly  as  it  is  generated,  with  the  elements 
of  the  tooth  structure,  and  that  all  conditions  necessary  for  its  forma- 
tion exist  in  the  mouth. 

From  the  fact  that  putrefying  animal  substance  has  been  found  in 
carious  cavities,  and  an  alkaline  reaction  instead  of  an  acid,  has  been 
obtained  from  tests  of  the  carious  matter  of  cavities.  Dr.  Miller  also 
disputes  the  presence  of  nitric  acid,  and  its  influence  in  producing 
"  white  decay." 

The  presence  of  sidphurie  acid  in  the  mouth  is  accounted  for  as 
follows :  Albumen  is  a  constituent  of  mucus,  and  is  contained  in  many 
articles  of  food.  Sulphur,  if  not  a  constituent  of,  is  always  united  with 
albumen.  Its  ordinary  presence  in  the  mouth  is  therefore  easily  ex- 
plained. Sulphur  and  oxygen  unite  directly,  under  various  circum- 
stances, as  in  the  combustion  of  sulphur,  but  it  is  probable  that  the 
union  here  is  effected  by  indirect  means.  Hydrosulphuric  acid,  or 
sulphuretted  hydrogen,  is  one  of  the  results  of  the  putrefactive  decora- 
position  of  albuminous  substances.  The  oxygen  of  the  atmosphere 
rapidly  decomposes  this  acid  by  taking  its  hydrogen  to  form  water. 
The  sulphur  is  therefore  set  free,  and  being  in  its  nascent  state,  its  affin- 
ities are  increased  in  energy,  and  it  also  unites  with  oxygen,  forming 
sulphurous  acid,  SO2,  which  in  the  presence  of  the  saliva  is  rapidly 
converted  into  sulphuric  acid,  or  SO^.  The  quantity  of  sulphur,  how- 
ever, present  in  the  mouth  at  any  one  time,  is  very  minute,  and  a  great 
proportion  of  this  is  exhaled  by  the  breath  before  it  has  time  to  undergo 
decomposition.  Sulphuric  acid  has  a  weaker  affinity  for  the  constitu- 
ents of  the  tooth  than  some  others ;  and  the  black  decay  resulting  is 
not  so  common  as  some  other  varieties,  and  progresses  less  rapidly ; 
and  as  from  the  nature  of  the  chemical  action  the  texture  of  the  tooth 
is  not  so  entirely  broken  up,  the  carbonized  portion  protects  the  parts 


CARIES    OF    THE    TEETH.  347 

beneath  it,  as  the  slow  and  prok:)nged  action  of  this  acid  on  the  gelati- 
nous portion  of  the  tooth  results  in  its  carbonization,  the  carbonized 
gelatin  being  "  animal  charcoal."  Sulphuric  acid  does  not  break  down 
the  texture  of  the  tooth  to  the  extent  that  some  other  acids  do,  because 
it  cannot  unite  with,  or,  under  ordinary  circumstances,  decompose  the 
principal  earthy  salt  of  which  it  is  composed.  Sulphuric  acid  is  fre- 
quently administei*ed  as  a  medicine.  The  escharotic  power  of  hydro- 
chloric acid  depends  mainly  on  its  affinity  for  water,  which  is  very 
active,  and  on  its  ability  to  coagulate  albumen.  "When  concentrated, 
it  dissolves  animal  tissues,  but  in  this  respect  is  far  inferior  to  nitric 
acid ;  its  chemical  action  is  generally  inferior  to  that  of  either  nitric 
or  sulphuric.  When  much  diluted,  and  mixed  with  dried  mucous 
membrane,  it  dissolves  coagulated  albumen,  fibrin,  etc.  Concerning 
the  action  of  hydrochloric  acid  on  the  tooth  :  the  carbonate  of  lime 
and  the  acid  are  mutually  decomposed,  the  results  being  chloride  of 
calcium,  water,  and  carbonic  acid.  The  carbonic  acid  escapes  as  a  gas, 
and  the  chloride  being  very  soluble,  is  dissolved  in  the  saliva,  and  thus 
removed  from  the  tooth.  The  phosphate  of  lime,  though  not  decom- 
posed by,  is  highly  soluble  in,  hydrochloric  acid.  It  is  dissolved  and 
thus  removed  from  the  organic  portion  of  the  tooth.  Hydrochloric 
acid  is  also  administered  as  a  medicine;  it  is  also  an  ingredient  of  the 
gastric  fluid,  and  is  often  present  in  abnormal  quantities  in  the  stomach, 
from  which  it  is  thrown  into  the  mouth  by  eructation  and  vomiting. 
It  may  also  be  present  in  the  saliva  when  the  latter  is  in  an  abnormal 
condition,  as  it  may  originate  in  the  decomposition  of  the  soluble 
chlorides  contained  in  the  saliva  and  mucus.  When  the  chlorine  of 
these  is  liberated  it  takes  hydrogen  from  the  water  of  the  saliva,  and 
this  acid  is  the  result  of  the  union.  It  is  also  sometimes  directly  fur- 
nished by  the  salivary  glands,  either  as  a  secretion  or  an  excretion  ; 
and  it  is  usually  found  in  the  mouth  when  the  mucous  membrane  is 
inflamed,  as  well  as  in  patients  who  indulge  in  the  excessive  use  of 
salted  meats.  Galvanic  currents  in  the  mouth  always  result  in  the 
formation  of  this  acid. 

What  is  known  as  the  "  septic  theory,"  is  explained  as  follows  by 
Dr.  C.  S.  Stockwell:  "  We  will  suppose  an  absolutely  perfect  tooth? 
the  enamel  absolutely  intact,  and  no  defects  whatever.  The  enamel 
in  such  a  case  forms  a  perfect  protection  against  the  micro-organisms. 
There  are  many  places  about  the  teeth,  however,  where  food  collects  and 
remains  undisturbed.  Xow  the  organisms  of  fermentation  operate  upon 
the  food  and  saliva,  and  the  result  is  an  acid.  This  acid  may  erode 
the  enamel  in  time,  so  that  a  portion  of  the  organic  tissue  of  the  tooth 
becomes  exposed  ;  organisms  may  then  act  directly  upon  the  fibrils  or 
organic  tissues ;  by  absorbing  the  protoplasm  they  weaken  its  vitality 


348  DENTAL  PATHOLOGY,  THERAPEUTICS. 

or  resisting  force,  disturb  nutrition,  set  up  inflammatory  action,  and 
the  result  is  stasis  and  death  of  the  organic  tissue;  after  which  the 
putrefactive  and  fermentative  stage  comes  in,  which  disposes  of  both 
the  organic  and  inorganic  portions  of  the  tooth.  We,  then,  first  have 
a  killing  of  a  portion  of  the  organic  tissue  as  a  result  of  the  action  of 
organisms — a  disease.  Secondly,  the  disposal  of  the  organic  and  inor- 
ganic by  putrefactive  and  fermentative  processes — caries."  He  also 
believes  that  the  putrefactive  and  fermentative  processes  may  be 
simultaneously  going  on,  and  that  they  are  essentially  identically 
alike;  and  the  result  of  one  is  alkali,  accompanied  by  an  odor — 
putrefaction ;  and  the  other  process  results  in  an  acid  without  the 
odor — fermentation  ;  and  that  these  processes  have  a  common  cause — 
organisms. 

The  foregoing  theories  of  the  cause  of  dental  caries  explains  the 
rationale  of  the  treatment  at  present  adopted  for  arresting  its  progress. 
By  the  removal  of  the  decomposed  part,  and  filling  the  cavity  with  an 
indestructible  material,  the  contact  of  those  agents  upon  the  chemical 
action  of  which  the  disease  depends,  is  prevented,  and  the  further  pro- 
gress of  the  decay  arrested. 

PREVENTION   OF    CARIES. 

It  is  an  old  adage,  no  less  true  than  trite,  that  "  an  ounce  of  preven- 
tion is  better  than  a  pound  of  cure,"  and  in  the  present  instance  it  may 
be  applied  with  its  full  force.  Were  more  attention  paid  to  the  prac- 
tical instruction  thus  conveyed,  many  of  the  diseases  of  the  teeth  might 
be  avoided.  Most  of  the  remarks  that  might  be  made  on  this  subject 
have  been  anticipated  ;  consequently,  it  will  only  be  necessary  to  ob- 
serve, that  if  the  teeth  are  well  formed  and  well  arranged,  all  that  will 
be  required  is  to  keep  them  clean  ;  if  any  irregularity  occurs,  it  should 
be  remedied  by  the  means  before  described. 

For  cleansing  the  teeth,  when  they  are  in  a  sound  condition  and  free 
from  calcareous  deposits,  the  gums  healthy,  and  the  secretions  of  the 
mouth  normal  in  character,  the  regular  and  frequent  use  of  pure  water 
by  means  of  a  proper  brush  and  waxed  floss  silk  will,  in  most  cases,  be 
sufiicient.  But  when  the  enamel  is  stained  and  discolored,  and  the  se- 
cretions of  the  mouth  inclined  to  acidity,  with  a  tendency  to  calcareous 
deposits,  then  the  employment  of  a  dentifrice  is  necessary. 

Dentifrice — from  dens,  a  tooth,  and  firieo,  fricare,  to  rub — is  a  medi- 
cinal preparation,  in  the  form  of  a  powder,  for  cleansing  the  teeth. 
An  almost  numberless  variety  of  dentifrices  are  in  use,  and  many  of 
them  highly  injurious.  In  the  preparation  of  an  agent  of  this  kind, 
the  object  should  be  to  obtain  a  compound  pleasant  to  the  taste,  alto- 
gether free  from  acids  and  acrid  substances,  and  soluble  or  insoluble, 


CARIES   OF   THE   TEETH.  349 

according  to  the  nature  of  the  case  in  which  it  is  to  be  used  ;  one  ca- 
pable of  neutralizing  and  removing  acrid  and  fermenting  matters 
secreted  between  the  teeth,  and  also  allaying  irritation.  A  dentifrice, 
then,  should  be  anti-acid,  and,  moreover,  a  powder;  and  the  more 
simple  the  preparation  the  better.  A  preparation  composed  of  orris 
root,  prepared  chalk,  and  pure  Castile  or  white  Windsor  soap,  to  which 
may  be  added  very  finely  powdered  cuttle-fish  bone  or  pumice-stone, 
for  the  removal  of  calcareous  matter,  when  there  is  a  tendency  to  de- 
.  posits  of  this  nature,  wall  answer  every  purpose.  AVhen  the  gums  are 
in  a  healthy  condition,  there  is  no  use  for  such  ingredients  in  a  denti- 
frice as  Peruvian  bark  or  myrrh,  and  as  for  liquid  dentifrices,  they  are 
of  very  little  use,  for  the  object  in  using  the  brush  is  friction,  and  as 
these  liquid  preparations  are  generally  lubricating  alkaline  substances, 
they  cause  the  brush  to  pass  so  easily  over  the  teeth  as  to  render  them 
almost  useless.  In  many  cases  an  unhealthy  condition  of  the  gums  is 
owing  to  the  irritation  produced  by  local  irritants,  and  their  removal  is 
all  that  is  needed  to  restore  them  to  health.  Soap  alone  will  not  cleanse 
the  teeth,  for  it  prevents  friction ;  and  charcoal,  notwithstanding  its 
detergent  and  antiseptic  properties,  is  injurious  as  a  dentifrice,  or  as  an 
ingredient  of  one,  on  account  of  its  insinuating  itself  under  the  free 
margin  of  the  gum,  and  causing  it  to  recede  from  the  neck  of  the  tooth, 
no  matter  how  finely  it  may  be  pulverized.  Either  of  the  following 
dentifrices  may  be  used  : — 

R.     Prepared  chalk ,^  iv 

Powdered  orris  root ^iv 

Powdered  cinnamon  ^W 

Sup.  carb.  of  soda jss 

White  sugar ..  ^j 

Oil  of  lemon.  .  gtt.  xv 

Oil  of  rose gtt.  ij. 

H.     Prepared  chalk ,^ij 

Powdered  orris  root ^ij 

Pumice  stone 5J. 

Ingredients  in  both  prescriptions  to  be  thoroughly  pulverized  and  well  mixed. 

The  importance  of  keeping  the  teeth  clean  cannot  be  too  strongly 
impressed  upon  the  mind  of  every  individual.  Proper  attention  to 
the  cleanliness  of  these  organs  contributes  more  to  their  health  and 
preservation  than  is  generally  supposed.  Against  caries  it  is  a  most 
powerful  prophylactic.  "  When  the  teeth,"  says  Dr.  L.  S.  Parmly, 
"  are  kept  literally  clean,  no  disease  will  ever  be  perceptible.  Their 
structure  will  equally  stand  the  summer's  heat  and  winter's  cold,  the 
changes  of  climate,   the  variation  of  diet,  and  even  the  diseases  to 


350  DENTAL  PATHOLOGY,  THERAPEUTICS. 

which  the  other  parts  of  the  body  may  be  subject  from  constitutional 
causes." 

The  configuration  and  arrangement  of  some  teeth  is  such,  however, 
as  to  preclude  the  possibility  of  keeping  them  clean ;  but  this  should 
not  deter  any  one  from  using  the  proper  means,  for  if  disease  is  not 
wholly  prevented,  they  will,  at  least,  contribute  very  greatly  to  the 
preservation  of  the  organs. 

The  subject  of  "food  in  relation  to  the  teeth,"  has  claimed  the  atten- 
tion of  eminent  writers,  many  of  whom  are  convinced  that  strict 
attention  on  the  part  of  the  mother  to  hygienic  laws ,  from  the  time  of 
conception,  will  influence  for  good  the  structural  quality  of  the  develop- 
ing tooth  tissues  of  the  child.  As  phosphate  of  lime  is  an  important 
ingredient  of  the  tooth  tissues,  it  is  urged  that  the  requisite  quantity  of 
this  lime  salt  should  be  supplied  with  the  food,  and  that  due  attention 
to  the  laws  of  health  in  regard  to  exercise,  rest,  ventilation,  bathing, 
etc.,  will  cause  the  lime  salt  to  be  assimilated  and  properly  appropri- 
ated in  the  formation  and  development  of  tooth  tissues.  Many  also 
believe  that  foods  prepared  by  artificial  means  are  very  serviceable  in 
supplying  such  elements  as  fail  to  be  assimilated  in  the  ordinary  man- 
ner ;  hence  the  use  during  pregnancy  and  lactation  of  preparations  of 
the  syrup  of  the  lactophosphate  of  lime,  wheat  phosphate,  and  such 
articles  of  diet  as  oatmeal,  cracked  wheat,  etc.,  are  recommended  as 
being  of  great  benefit.  No  doubt  the  amount  of  phosphate  to  be  used 
by  the  system  will  depend  in  a  great  measure  upon  the  digestion. 


CHAPTER  XXV. 

MALFORMED   TEETH. 


PECULIARITIES  in  the  Formation  and  Growth  of  the  Teeth.— In 
the  development  and  growth  of  the  various  parts  of  the  body, 
curious  and  interesting  anomalies  are  sometimes  observed ;  but  in  no 
portion  of  it  are  they  more  frequent  in  their  occurrence  or  diversified 
in  their  character  than  in  the  teeth.  But  aberrations  in  the  formation 
and  growth  of  these  organs  are,  for  the  most  part,  confined  to  the 
teeth  of  second  dentition. 

Although  the  deciduous  teeth  are  much  more  exempt  from  deviations 
in  form,  size  and  number,  than  the  permanent  teeth,  yet  they  are  not 
altogether  free  from  such  irregularities.  One  form  of  irregularity  of 
these  teeth  may  consist  in  a  greater  number  than  twenty  ;  while  in  other 


MALFORMED   TEETH.  351 

cases  there  may  be  a  numerical  deficiency.  De- 
ciduous teeth,  especially  the  molars,  are  occa-  ^^^-  ^^^•*  ^^^-  ^^'^■'^ 
sionally  met  Avith  having  more  than  the  normal 
number  of  roots.  A  more  common  form  of 
irregularity  is  the  union  of  two,  or  sometimes 
even  three,  deciduous  teeth,  generally  incisors,  or 
an  incisor  and  a  canine,  either  by  a  union  in  the 
cementum,  or  in  the  dentine  and  enamel.    When 

the  union  is  in  the  cementum,  the  roots  only  are  united,  but  where  it 
is  in  the  dentine  and  enamel  there  is  a  fusion  of  both  the  crowns  and 
the  roots,  and  one  pulp  common  to  the  two  teeth  (geminous). 

Malfokinied  Permanent  Teeth. — Irregularity  in  the  forms  of  per- 
manent teeth  is  much'  more  common  than  is  the  case  with  deciduous 
teeth ;  some  of  the  former  differing  so  much  in  size,  either  above  or 
below  what  is  normal,  as  to  occasion  disfigurement ;  in  the  same  mouth 
very  large  teeth  may  be  associated  with  others  extremely  small,  or 
the  malformation  may  be  confined  to  a  single  tooth  of  the  set.  But 
examples  of  this  kind  are  not  very  frequent ;  for  where  there  is  an 
increase  or  diminution  in  the  size  of  the  teeth  of  one  class,  there  is 
generally  a  corresponding  change  in  that  of  the  other. 

Aberrations  of  this  character  are  probably  dependent  upon  some 
diathesis  of  the  general  system,  whereby  the  teeth,  during  the  earlier 
stages  of  their  formation,  are  supplied  with  an  excessive  or  diminished 
quantity  of  nutriment.  Again  the  malformation  may  be  confined  to 
the  root,  while  the  crown  of  the  tooth  is  of  the  normal  size. 

A  superior  central  incisor  may  have  a  root  which  is  abnormally 
small,  while  the  crown  is  of  the  usual  size. 

Another  malformation  consists  in  an  excess  of  the  normal  number 
of  roots,  the  superior  molars  sometimes  having  four  or  six  slender 
roots,  and  the  inferior  molars  three  and  four,  the  inferior  canines  two, 
and  the  superior  bicuspids  three  roots.  The  variations  in  form  of 
the  permanent  teeth  are  beyond  enumeration  ;  in  some  cases  teeth 
with  single  roots  are  bent  at  different  angles.  The  crowns  of  the 
teeth,  also,  frequently  present  deviations  from  the  natural  shape 
equally  striking  and  remarkable. 

*  Shows  the  front  view  of  the  lateral  incisor  and  canine  from  the  left  side  of 
the  under  jaw,  united  throughout  their  entire  length,  but  with  the  line  of  junction 
well  marked.  The  age  at  which  they  were  removed  was  seven  years.  The 
coiresi:)onding  teeth  on  the  opposite  side  of  the  jaw  were  similarly  united. 

t  Shows  the  representation  of  the  lateral  incisor  and  canine  from  the  left  side 
of  the  lower  jaw  of  a  patient  aged  nine  years.  In  this  example  the  line  of  junc- 
tion is  less  distinctly  marked  than  in  the  preceding  illustration,  and  is  altogether 
wanting  near  the  base  of  the  enamel. 


352  DENTAL  PATHOLOGY,  THERAPEUTICS. 

Figs.  108  and  109  represent  incisor  teeth  with  malformed  roots. 

Teeth  with  flexed  roots  are  also  met  with.  Figs.  110  and  111 
represent  superior  central  incisors  with  single  and  double  flexions  of 
the  roots. 

Mr.  Fox  gives  a  drawing  of  a  tooth  very  much  resembling  the 
letter  S.  The  malformation  was  caused  by  an  obstructing  temporary 
tooth.  The  author  has  also  met  with  several  examples  of  teeth 
similarly  deformed,  and  from  like  causes. 

Some  very  remarkable  deviations  have  been  known  to  take  place  in 
the  growth  of  the  teeth.  The  most  singular  case  on  record  is  that 
related  by  Albinus.  "Two  teeth,"  says  he,  "  between  the  nose  and 
the  orbits  of  the  eye,  one  on  the  right  side  and  the  other  on  the  left, 
were  inclosed  in  the  roots  of  those  processes  that  extend  from  the 
maxillary  bones  to  the  eminence  of  the  nose.  They  were  large,  re- 
markably thick,  and  so  very  like  the  canines  that  they  seemed  to  be 
these  teeth,  which  had  not  before  appeared;  but  the  canines  themselves 
were  also  present,  more  than  usually  small  and  short,  and  placed  in 
their   proper   sockets.     The   former,  therefore,  appear   to  have  been 

Fig.  108.  Fig.  109.  Fig.  110.  F^^.  111. 


«5 


new  canines,  which  had  not  penetrated  their  sockets,  because  they  were 
situated  where  these  same  teeth  are  usually  observed  to  be  in  children. 
But  what  is  still  more  remarkable,  their  points  were  directed  toAvard 
the  eyes,  as  if  they  were  the  new  eye  teeth  inverted.  And  they  were 
also  so  formed  that  they  were,  contrary  to  what  usually  happens,  convex 
on  the  posterior  and  concave  on  the  anterior."  A  case  of  a  somewhat 
similar  character  is  mentioned  by  Mr.  John  Hunter. 

The  following  case  is  in  the  words  of  Mr.  G.  Wait :  "  While  I  was 
prosecuting  my  anatomical  studies,  I  was  struck  with  the  appearance 
of  a  cuspid  of  the  upper  jaw;  it  was  short,  and  appeared  as  if  the  body 
of  the  tooth  was  in  the  jaw,  and  that  it  was  the  tip  of  the  root  that 
jiresented  itself.  Upon  further  examination  I  found  this  verified,  and 
after  the  cranium  and  lower  jaw  were  properly  macerated  and  cleansed, 
1  found  one  of  the  lower  bicuspids  in  the  same  position." 

The  following  is  one  of  the  several  cases  of  deviation  in  the  growth 
of  the  teeth,  that  have  come  under  the  author's  observation  :  In  1840, 
he  was  requested  to  extract  a  tooth  for  a  lady  of  Baltimore,  under  the 


MALFORMED   TEETH.  353 

following  circumstances.  She  had,  for  a  time,  experienced  a  great 
deal  of  pain  in  her  upper  jaw,  and  supposed  it  to  originate  from  the 
second  molar  of  the  right  side,  but  which  was  perfectly  sound.  Mean- 
while her  general  health  became  impaired,  and  her  attending  physi- 
cian, thinking  that  the  local  irritation  might  have  contributed  to  her 
debility,  advised  the  extraction  of  the  tooth.  On  removing  it,  the 
cause  of  the  pain  at  once  became  apparent.  The  dens  sapientise,  which 
had  not  hitherto  appeared,  was  discovered  with  its  roots  extending 
back  to  the  utmost  verge  of  the  angle  of  the  jaw,  while  its  grinding 
surface  had  been  in  contact  with  the  posterior  surface  of  the  crown 
and  neck  of  the  tooth  just  extracted.  On  the  removal  of  the  wisdom 
tooth,  the  pain  ceased. 

About  the  middle  of  December,  1849,  a  youth  aged  sixteen  applied 
to  the  author  to  extract  a  right  superior  bicuspid,  which,  he  said,  was 
ulcerated  at  the  root.  On  examining  his  mouth,  he  discovered  only 
one  bicuspid,  but  above  and  between  the  root  of  this  and  that  of  the 
first  molar,  he  observed  a  small  fistulous  opening.  On  introducing  a 
small  probe,  it  immediately  came  in  contact  with  the  crown  of  a  tooth 
looking  toward  the  malar  process  of  the  superior  maxillary,  which,  on 
extraction,  proved  to  be  the  second  bicuspid. 

The  author  has  in  his  possession  several  molar  and  bicuspid  teeth 
which  have  small  nodes  upon  their  necks,  covered  with  enamel ;  and 
there  is  a  jaw  in  the  Museum  of  the  Baltimore  Dental  College  which 
has  five  teeth  presenting  this  anomaly. 

The  author  has  two  teeth  in  his  possession  of  most  singular  shape, 
presented  to  him  by  his  brother,  the  late  Dr.  John  Harris.  They  were 
extracted  in  July,  1822,  from  the  right  side  of  the  upper  jaw  of  a 
young  gentleman,  nineteen  years  of  age,  by  the  name  of  Crawford. 
They  occupied  the  place  of  the  first  and  second  bicuspids,  and  their 
crowns  are  almost  wholly  imbedded  in  lamellated  dentine,  that  should 
have  constituted  their  roots,  but  which  are  entirely  wanting.  Judging 
from  their  appearance,  one  would  be  inclined  to  suppose  that  their 
sacs  failing  to  contract,  they  remained  stationary  in  their  sockets,  and 
as  the  base  of  the  pulps  elongated,  they  came  in  contact  with  the 
bottom  of  the  alveoli,  and  were  caused  to  bulge  out  and  to  be  reflected 
upon  their  crowns,  to  the  enamel  of  which,  nearly  to  their  grinding 
surfaces,  they  are  perfectly  united.  For  some  time  previously  to  the 
extraction  of  these  teeth,  they  had  been  productive  of  considerable 
irritation  and  pain  in  the  gums  and  jaw,  and  it  was  for  the  relief  of 
the  sufiering  which  their  presence  induced  that  they  were  removed. 

Since  the  publication  of  the  second  edition  of  this  work,  the  author 
has  seen  a  still  more  remarkable  deviation  in  the  growth  of  a  tooth. 
It  is  in  the  upper  jaw  of  an  adult  skull  in  which  the  natural  teeth  are 

23 


354  DENTAL  PATHOLOGY,  THERAPEUTICS. 

all  well  formed  and  regularly  arranged  in  the  alveolar  border,  but 
between  the  extremities  of  the  roots  of  the  superior  central 
incisors,  in  the  substance  of  the  jaw,  there  is  a  supernu- 
merary tooth,  the  crown  of  which  looks  upward  toward  the 
crest  of  the  nasal  plates  of  the  two  bones.  The  whole  tooth 
is  about  one  inch  in  length,  and  the  apex  of  the  crown  is 
nearly  on  a  level  with  the  floor  of  the  nasal  cavities.  There 
is  also  in  the  Dental  Museum  of  the  University  of  Maryland 
a  central  incisor  of  the  upper  jaw,  with  the  root  bent  upon,  and  in  con- 
tact with,  the  labial  surface  of  the  crown  (Fig.  112). 

United  Teeth. — Inclosed  as  each  tooth  is  in  a  distinct  sac,  and  sepa- 
rated on  either  side  by  a  bony  partition,  from  the  adjoining  teeth,  until 
after  the  completion  of  the  formation  of  the  enamel,  it  may  be  difficult 
to  conceive  how  osseous  union  could  take  place  between  two  of  these 
organs,  but  so  many  examples  of  such  a  union  are  met  with,  that  there 
is  no  longer  any  question  concerning  its  possibility. 

Two  or  more  teeth,  generally  the  molars,  may  be  permanently  joined 
together  by  a  union  in  the  cementum  of  their  roots,  occasioned  by 
diseased  action,  such  as  exostosis,  taking  place  after  the  complete 
development  of  the  teeth.  The  term  "osseous  union"  has  been 
applied  to  such  cases. 

Fig.  113  represents  united  second  and 
third  molars,  the  one  figure  presenting 
the  buccal  aspect,  and  the  other  the 
palatal. 

During  a  visit  to  the  city  of  Richmond, 
Va.,  we  had  an  opportunity  of  seeing 
two  cases.  One  consisted  in  the  union 
of  the  crowns  of  the  central  incisors  of 
the  upper  jaw,  the  palatine  surface  of 
which  presented  the  appearance  of  one 
broad  tooth,  while  anteriorly  they  had  the  semblance  of  two  teeth ; 
the  other  case  consisted  in  the  union  of  the  right  central  and  lateral 
incisors  of  the  lower  jaw. 

A  professional  friend  informed  the  author,  in  a  conversation  some 
years  since,  that  he  had  met  with  a  case  of  osseous  union  between  a 
second  bicuspid  and  first  molar  of  the  lower  jaw,  which  was  so  palpable 
that  there  could  have  been  no  doubt  of  its  existence. 

Cases  of  this  nature  are  of  rare  occurrence,  and  a  connection  of  the 
roots  of  two  teeth,  by  an  intervening  portion  of  the  alveolus,  is  very 
easily  mistaken  for  osseous  union  of  the  roots  themselves.  A  few  years 
since,  in  extracting  a  second  molar  of  the  upper  jaw,  the  author  brought 
the  dens  sapientise  along  with  it.    At  first  he  thought  there  was  osseous 


MALFORMED    TEETH.  355 

union  of  the  roots,  but  upon  close  examination  found  a  very  thin 
portion  of  the  alveolar  wall  between,  to  which  their  roots  were  firmly- 
attached.  Such  a  case  as  this  would,  in  many  instances,  be  set  down 
as  an  example  of  osseous  union. 

An  osseous  union  of  the  teeth  is,  fortunately,  of  rare  occurrence  ; 
if  it  were  otherwise,  it  would  be  productive  of  many  accidents  in  the 
extraction  of  teeth.  Apart  from  this  consideration,  it  can  be  of  but 
little  importance  either  to  the  practitioner  or  to  the  physiologist. 

Since  the  publication  of  the  first  edition  of  this  work,  a  number  of 
cases  of  osseous  union  of  the  teeth  have  fallen  under  the  observation 
of  the  author.  Among  them  are  a  number  of  examples  of  osseous 
union  of  the  temporary  teeth. 

Geviinous  or  Fused  Teeth. — When  two  teeth  are  united  by  a  union 
in  the  enamel  and  dentine  throughout  the  entire  length  of  their  crowns 
and  roots,  they  are  termed  "  geminous  "  or  "  fused  "  teeth,  as  the  mal- 
formation is  occasioned  by  a  fusion  of  their  pulp,  from  close  proximity 
and  pressure,  one  pulp  being  common  to  the  two  teeth.    The  two  central 

Fig    114.  Fig.   115. 


incisors,  and  the  lateral  incisors  and  canines  are  more  commonly 
joined  together  in  this  manner  than  any  of  the  other  teeth.  Fig.  114 
represents  geminous  central  and  lateral  incisors,  showing  the  labial 
and  palatal  aspects,  these  specimens  being  in  the  Dental  Museum  of 
the  University  of  Maryland. 

Other  cases  occur  where  the  union  or  fusion  is  confined  to  the  crowns 
of  the  teeth,  the  roots  being  separate. 

Fig.  115  represents  two  geminous  central  incisors,  the  crowns  of 
which  are  united  while  the  roots  are  separate. 

Supernumerary  Teeth. — The  development  of  supernumerary  teeth  is 
usually  confined  to  the  anterior  part  of  the  mouth,  and  moj-e  frequently 
to  the  upper  than  to  the  lower  jaw.  They  sometimes,  however,  appear 
as  far  back  as  the  dentes  sapientise,  and  Hudson  says  he  has  seen  them 
behind  these  teeth.  We  have  now  in  our  anatomical  collection,  two 
supernumerary  teeth  that  were  extracted,  one  from  behind  and  the 
other  at  the  side  of  one  of  the  upper  wisdom  teeth.* 

*  These  teeth  were  removed  by  Dr.  Chewning,  dentist,  of  Fredericksburg,  Va. 


356  DENTAL  PATHOLOGY,  THERAPEUTICS. 

The  crowns  of  supernumerary  teeth  which  appear  in  the  anterior 
part  of  the  mouth  are  usually  of  a  conical  shape,  and  for  the  most  part 
situated  between  the  central  incisors  ;  they  usually  have  short,  knotty 
roots;  sometimes,  however,  they  bear  so  strong  a  resemblance  to  the 
other  teeth  that  it  is  difficult  to  distinguish  the  one  from  the  other. 
We  once  saw  two  lateral  incisors  in  the  lower  jaw,  both  of  which  were 
so  well  arranged,  and  perfectly  formed,  that  it  was  impossible  to  de- 
termine which  of  the  two  ought  to  be  considered  as  the  supernumerary. 
Mr.  Bell  mentions  a  case  in  which  there  were  five  lower  incisors,  all 
of  which  were  well  formed  and  regularly  arranged.  The  author  has 
met  with  several  examples  in  which  supernumerary  teeth  in  the  lower 
jaws  so  closely  resembled  the  natural  incisors  that  no  difference  could 
be  discerned  between  them.  He  has  also  seen  examples  of  three  lat- 
eral incisors  in  the  upper  jaw,  where  it  was  impossible  to  determine 
which  was  the  supernumerary. 

Supernumerary  cuspids  rarely  if  ever  occur,  but  supernumerary 
bicuspids  are  occasionally  met  with.  Delabarre  says  he  has  seen  them  ; 
and  we  have  met  with  three  examples  of  the  sort ;  in  each  of  these 
instances  the  teeth  were  very  small,  not  being  more  than  one-fourth  as 
large  as  the  natural  bicuspids,  with  oval  crowns  and  placed  partly  on 
the  outside  of  the  circle  and  partly  between  the  bicuspids.  We  ex- 
tracted one  of  them,  and  have  it  still  in  our  possession.  Its  root  is 
short,  round,  and  nearly  as  thick  at  its  extremity  as  it  is  at  the  neck  of 
the  tooth. 

The  supernumerary  teeth  that  appear  further  back  than  the  bicus- 
pids, though  much  smaller,  bear  a  strong  resemblance  to  the  dentes 
sapientise. 

Supernumerary  teeth,  although  generally  imperfect  in  their  forma- 
tion, are  less  liable  than  other  teeth  to  decay.  This  may  be  attribut- 
able to  the  fact  that  they  are  harder,  and,  consequently,  not  so  suscep- 
tible to  the  action  of  the  causes  that  produce  the  disease. 

Although  the  occurrence  of  supernumerary  teeth  rarely  disturbs  the 
arrangement  of  the  others,  their  presence  is  sometimes  productive  of 
the  worst  kind  of  irregularity ;  and  even  when  they  do  not  have  this 
effect,  they  impair  the  beauty  of  the  mouth,  and,  for  this  reason,  should 
be  extracted  as  soon  as  their  crowns  have  completely  emerged  from 
the  gums. 

To  the  practitioner  of  dental  surgery,  the  occurrence  of  supernu- 
merary teeth  is  interesting,  only  in  so  far  as  it  affects  the  beauty  of 
the  mouth  and  the  relationship  which  the  teeth  of  the  upper  jaw 
sustain  to  those  of  the  lower  ;  but  to  the  physiologist  it  involves  the 
question,  what  determines  their  development?  In  propounding  this 
interrogatory,  however,  it  is  not  our  intention  to  enter  upon  its  dis- 


MALFORMED   TEETH. 


357 


ciission  in  this  place,  as  it  forms  no  part  of  the  design  of  the  present 
treatise.     (See  "  Origin  of  Permanent  Teeth.") 

Supplemental  Teeth. — The  term  supplemental  is  employed  to  desig- 
nate teeth  which  resemble  in  shape  and  size  those  of  the  regular  series, 
as  a  third  lateral  incisor  or  canine,  or  a  fifth  bicuspid,  in  either  the 
upper  or  lower  jaw,  the  additional  teeth  being  perfectly  normal  in  form. 
Such  teeth  are  extremely  rare,  and  should  not  be  confounded  with 
supernumerary  teeth. 

Nodular  Teeth. — Occasionally  teeth  are  found  having  small,  white, 
pearly  nodules  on  their  necks,  or  upon  the  roots  near  the  termination 
of  the  enamel.  These  enamel  nodules  consist  of  a  thick  layer  of 
enamel  covering  a  cone  of  dentine,  which  projects  from  the  neck  or 
root  of  the  tooth,  and  contains  dentinal  tubuli.  They  are  similar  to  the 
excrescences  in  the  form  of  extra  cusps,  which  are  sometimes  found  on 
the  crowns  of  the  teeth,  especially  the  molars,  and  the  enamel  covering 
them  is  formed  by  a  true  enamel  organ.     These  nodules  are  of  physi- 


FiG.  118. 


Fig.  116. 


Fig.  117. 


A.  Smooth  enamel  coat- 
ed surface;  6.  nodules  of 
enamel. 

ological  interest  only,  as  they  do  not  give  rise  to  any  pathological 
symptoms.  They  are  a  variety  of  dental  exostosis  which  is  extremely 
rare  and  difficult  to  account  for.  Sometimes  they  may  be  mistaken  for 
supernumerary  teeth,  and  an  attempt  to  remove  them  result  in  the 
extraction  of  the  tooth  to  which  they  are  attached. 

Figs.  116  and  117  represent  permanent  teeth  with  nodules  of  enamel 
attached  to  the  necks  and  sides  of  the  roots. 

Odontomes. — This  term  has  been  generally  applied  to  tooth  tumors 
developed  from  the  hard  tissues  of  the  teeth,  but  it  is  now  restricted  to 
those  irregular  masses  of  dentinal  tissues  which  result  from  some 
hypertrophied  condition  of  the  tooth  papilla  or  formative  pulp.  In 
such  cases  the  irregular  mass  consists  of  dentine  and  enamel,  bearing 
little  or  no  resemblance  to  a  tooth ;  and  it  originates  after  the  com- 
mencement of  calcification. 

Fig.  118  represents  an  odontome  consisting  of  an  irregular  mass  of 
tooth  tissues. 


358 


DENTAL  PATHOLOGY,  THERAPEUTICS. 


The  teeth  described  by  Salter,  Wedl  and  others,  under  the  name 
of  "  Warty  Teeth,"  and  which  are  composed  of  tissues  hypertrophied 
and  folded  together  into  an  irregular  and  complicated  mass,  afford  a 
fair  example  of  odontomes. 

It  is  not  unusual  for  odontomes  to  remain  in  the  mouth  for  a  con- 
siderable time  without  causing  trouble,  but  sooner  or  later  they  may 
give  rise  to  inflammation  followed  by  suppuration  in  the  adjoining 
parts,  when  their  immediate  removal  is  necessary.  Mr.  John  Tomes 
refers  to  a  case  where  the  body  of  the  sphenoid  bone  was  found  to  be 
the  seat  of  a  tumor  containing  dentine. 

Syphilitic  Teeth. — Mr.  J.  Hutchinson  was  the  first  to  call  attention  to 
a  class  of  malformed  jDcrmanent  teeth,  the  result  of  inherited  syphilis, 
and  he  asserts  that  certain  deviations  in  the  forms  of  teeth  are  valuable 
.as  diagnostic  marks  of  the  existence  of  syphilis  of  a  congenital  consti- 
tutional type,  and  he  classes  them  with  syphilitic  interstitial  keratitis 


Fig.  119. 


iii"|lSI|l|nII"  'lli'llf  111  rin*|"«"   « 


i      \  J«Al*il'  ' 


Fig.  120. 


This  author  describes  syphilitic  teeth  as  follows  :  "  In  those  who  had  cut 
their  permanent  teeth  the  condition  of  the  incisor  teeth  was  very 
peculiar,  both  in  form,  color  and  size.  As  a  diagnostic  of  hereditary 
syphilis,  various  peculiarities  are  often  presented  by  the  others,  espe- 
cially the  canines ;  but  the  upper  central  incisors  are  the  test  teeth. 
When  first  cut,  these  teeth  are  short,  narrow  from  side  to  side  at  their 
edges,  and  very  thin.  After  awhile  a  crescentic  portion  from  their 
edge  breaks  away,  leaving  a  broad,  shallow,  vertical  notch,  which  is 
permanent  for  some  years,  but  between  twenty  and  thirty  usually  be- 
comes obliterated  by  the  premature  wearing  down  of  the  teeth.  The 
two  teeth  often  converge,  and  sometimes  they  stand  widely  apart.  In 
certain  instances  in  which  the  notching  is  either  wholly  absent  or  but 
slightly  marked,  there  is  still  a  peculiar  color  and  a  narrow  squareness 

of  form,  which  are  easily  recognized  by  the  practiced  eye 

Indeed,  there  can  be  no  doubt  whatever  as  to  the  truth  of  the  assertion 


lyfALFORMED   TEETH.  359 

that  malformed  upper  incisors  (permanent  set)  are  all  but  invariably 
coincident  with  this  disease." 

Henry  W.  Williams,  m.  d.,  Professor  of  Ophthalmology  in  Harvard 
University,  confirms  Mr.  Hutchinson's  observations,  and  says :  "  The 
central  incisors  of  the  second  dentition  have  a  peculiar  crescentic  notch 
at  their  lower  margins,  and  the  lateral  incisors  and  canines,  as  well  as 
the  molars,  are  often  small,  peg-shaped,  and  with  tuberculated  promi- 
nences upon  their  surface.  They  are,  perhaps,  also  irregularly  set  in 
the  jaw,  and  of  bad  color,  or  prematurely  decayed." 

Figs.  119  and  120  represent  syphilitic  teeth  in  a  boy  and  two  girls, 
aged  respectively  twelve,  fourteen  and  seventeen  years. 

Mr.  John  Tomes  describes  these  teeth  as  being  of  "  a  dusky,  opaque 
appearance,  and  are  small  relatively  to  the  size  of  the  jaws,  so  that 
distinct  intervals  are  left  between  them ;  moreover,  they  are  of  a  very 
soft  character,  so  that  they  speedily  become  worn  down,  and  the  char- 
acteristic transverse  notch  obliterated."  Mr.  Hutchinson  remarks : 
"  Inasmuch  as  specific  inflammations  do  not  occur  during  the  period 
of  iutra-uterine  life,  the  teeth  belonging  to  the  deciduous  series  are  not 
liable  to  be  affected,  though  they  may  be  lost  by  exfoliation  consequent 
on  stomatitis  and  periostitis.  On  the  other  hand,  the  occurrence  of 
specific  affections  of  the  mouth  soon  after  birth  may  be  readily  sup- 
posed to  affect  the  permanent  teeth  which  are  at  this  time  developing, 
and  certain  characters  are  enumerated  as  indicative  of  such  interfer- 
ence with  the  growing  teeth." 

Deviation-s  of  the  teeth  from  the  normal  condition  are  so  numerous 
and  varied  in  their  character,  that  it  would  be  impossible  to  describe 
all  of  them. 

Under  the  title  of  "  dilaeeratlon,"  Mr.  John  Tomes  describes  a  con- 
dition of  tooth  resulting  from  displacement  of  the  calcified  portion  of 
a  tooth  from  the  tissues  which  were  instrumental  in  its  production,  the 
development  being  continued  after  the  normal  position  of  the  calcified 
portion  was  lost ;  for  example,  the  crown  of  an  incisor  when  partly 
formed  may  move  from  its  position  upon  the  pulp,  and  be  turned  out- 
ward or  inward,  or  to  either  side,  and  there  remain  in  a  state  of  rest, 
the  development  of  the  tooth  continuing  with  the  displacemept  of  one- 
half  of  the  crown  permanently  preserved. 

Fig.  121  represents  three  cases  Fig.  121. 

of  dilaceration,  two  incisors  and 
'a  bicuspid.  IIU  l|'|1 

Teeth  have  also  been  found 
with  the  root  at  its  ajDex  ex- 
panded into  a  cup-shaped  disk, 
on  the  margins  of  which  are  several  openings  or  foramina  for  the 


360 


DENTAL,  PATHOLOGY,  THERAPEUTICS. 


entrance  of  the  nerves  and  vessels.  Also  teeth  with  dentine  excres- 
cences in  the  form  of  nodules  growing  from  the  wall  of  the  pulp 
chamber.  Sometimes  these  nodules  of  secondary  dentine  almost  fill 
the  pulp  chamber,  while  the  parenchyma  of  the  pulp  is  extensively 
occupied  by  small  granules.  Such  excrescences  frequently  cause  pain 
of  a  neuralgic  character.  The  devitalization  of  the  pulp  is  the  only 
treatment. 

Dilated  roots  of  teeth  are  caused  by  the  dentinal  pulp  becoming 
hypertrophied  into  a  globular  structure  of  considerable  size,  and  when 
calcified  forming  an  osseous  mass,  often  larger  than  the  tooth  itself. 
Such  tumors  are  composed  of  an  outer  layer  of  cementum,  and  a  thin 
shell  of  dentine  enclosing  a  voluminous  pulp,  which  may  or  may  not 
be  calcified.  Dilated  roots  of  teeth  may  occasion  pain  when  the  jaws 
are  opened,  with  expansion  of  the  jaw  at  the  alveolar  portion. 

Malformed  teeth  also  result  from  interrupted  development  of  the 
dental  tissues,  which  is  manifested  by  the  crowns  irregularly  grooved 
or  pitted  and  smaller  than  the  natural  size.  The  incisors  are  generally 
thin  and  atrophied,  and  the  cusps  of  the  canines  and  molars  sharp 
pointed,  such  teeth  being  deficient  in  quantity  and  quality  of  their 
tissues,  and  of  a  yellow,  opaque  color. 

Fig.  122  represents  superior  and 
inferior  front  teeth  with  crowns 
disfigured  by  irregular  grooves 
and  pits.  (See  "  Atrophy  of  the 
Teeth.") 

Exostosed  teeth  are  also  in- 
cluded in  those  that  deviate  from 
the  normal  form,  one  of  the  most 
remarkable  instances  of  which 
was    a    case    exhibited    by   Mr. 

Fig.  123. 


Fig.  122. 


Tomes — a  molar  of  the  upper  jaw,  removed  from  a  patient  aged  forty- 
one,  who  had  long  suflTered  pain  in  the  jaw,  from  which  a  fistulous 
passage  led  through  the  cheek.  Fig.  123  represents  this  case.  (See 
"  Exostosis  of  the  Teeth.") 

Unerupted  or  Impacted  Teeth  are  often  malformed,  and  may  cause 
dentigerous  cysts.     (See  '•  Dentigerous  Cysts.") 


PART     THIRD. 


DENTAL   SURGERY. 


Besides  the  operations  of  General  Surgery  which  are  performed  upon  the 
mouth,  in  common  with  other  parts  of  the  body,  Dental  Science  gives  specific 
directions  for  those  operations  of  Special  Surgery  demanded  in  the — 

1.  Correction  of  Irregularities  in  the  Arrangement  of  the  Teeth. 

2.  Treatment  of  Dental  Caries. 

3.  Extraction  of  Teeth. 

4.  The  Use  of  Anesthetic  AGEXTa. 

5.  Dislocation  and  Fracture  of  the  Jaw. 

6.  Diseases  of  the  Maxillary  Sinus  or  Antrum. 

7.  Caries  of  the  Maxillary  Bones. 


CHAPTER  I. 


IRREGULARITY   OF   THE   TEETH, 


METHOD  of  Directing  Second  Dentition. — To  properly  direct  second 
dentition  a  knowledge  of  the  relative  position  of  the  permanent  and 
temporary  teeth  at  a  period  soon  after  the  appearance  of  the  first  teeth 
of  the  permanent  set,  is  necessary.  Fig.  124  represents  the  jaws  of  a 
child  about  six  years  of  age,  all  of  the  temporary  teeth  being  in  po- 
sition, and  the  six-year  molars  erupting. 

Fir.  124. 


The  developing  crowns  of  the  permanent  teeth  occupy  a  higher 
place  than  the  temporary  teeth,  and  the  superior  central  incisors  have 
a  more  outward  inclination,  on  account  of  their  size  and  the 
increased  width  of  the  arch  they  are  to  occupy  when  erupted.  The 
crowns,  and  a  small  portion  only  of  the  roots  of  these  teeth  are  com- 
pleted, and  they  are  placed  directly  under  and  in  contact  with  the  floor 
of  the  nares.  The  superior  lateral  incisors  are  not  so  far  advanced  in 
their  development  as  the  central  incisors,  and  their  crowns  are  situated 
beneath  the  angle  of  the  nares  and  back  of  the  roots  of  the  temporary 
laterals  and  canines. 

The  canines  are  situated  on  a  higher  plane  than  either  the  central  or 

363 


364  DENTAL,   SURGEEY. 

lateral  incisors,  not  more  than  one-fourth  of  an  inch  below  the  infra- 
orbital canals,  and  along  the  sides  of  the  outer  walls  of  the  nares,  with 
their  crowns  about  completed.  The  crowns  of  the  first  and  second 
superior  bicuspids  are  situated  on  the  same  plane  as  the  lateral  incisors, 
being  embraced  by  the  roots  of  the  first  and  second  temporary  molars, 
and  are  but  partly  developed.  The  crowns  of  the  first  permanent 
molars  of  both  jaws  have  erupted  and  are  about  antagonizing  with 
each  other,  but  their  roots  are  only  one-half  formed.  The  crowns  of 
the  permanent  second  molars  are  but  partly  developed,  and  are  situ- 
ated above  and  posterior  to  the  roots  of  the  first  permanent  molars, 
their  grinding  surfaces  having  a  direction  downward  and  slightly 
backward  toward  the  lower  portion  of  the  external  pterygoid  pro- 
cesses. The  dentes  sapientise  of  the  upper  jaw  are  represented  by 
small  crypts  only,  in  a  higher  plane  in  the  maxillary  tuberosities. 

The  inferior  permanent  central  incisors  are  situated  directly  behind  the 
roots  of  the  temporary  incisors,  and  have  their  crowns  completed  with 
about  one-fourth  of  their  roots.  The  roots  of  the  permanent  lateral  in- 
cisors are  not  so  far  developed,  and  are  situated  somewhat  back  of  the 
crowns  of  the  permanent  central  incisors  and  canines.  The  permanent 
central  and  lateral  incisors,  as  do  all  of  the  inferior  teeth,  occupy  a 
vertical  position  in  the  jaws,  on  account  of  the  inferior  dental  arch  being 
smaller  than  the  superior.  The  inferior  permanent  canines  occupy  a 
lower  plane  than  the  incisors,  and  their  partly  developed  roots  extend 
very  near  to  the  under  surface  of  the  bone  of  the  jaw.  The  position 
and  stage  of  development  of  the  inferier  permanent  bicuspids  and  first 
molars  are  about  the  same  as  those  of  the  corresponding  teeth  of  the 
upper  jaw. 

The  developing  crowns  of  the  permanent  second  molars  occupy  a 
higher  plane  than  that  of  the  bicuspids,  and  their  grinding  surfaces 
have  a  direction  upward  and  forward.  The  inferior  dentes  sapientise 
are  represented  by  small  crypts  only,  in  the  coronoid  processes. 

There  is  nothing  more  destructive  to  the  beauty,  health,  and  durability 
of  the  teeth,  and  no  disturbance  more  easily  prevented,  than  irregularity  of 
their  arrangement.  Also,  in  proportion  to  the  deviation  of  these  organs 
from  their  proper  position  in  the  alveolar  arch,  are  the  features  of  the 
face  and  the  expression  of  the  countenance  injured.  It  also  increases 
the  susceptibility  of  the  gums  and  alveolo-dental  membrane  to  morbid 
impressions. 

It  is  important,  therefore,  that  the  mouth,  during  second  dentition, 
should  be  properly  cared  for;  and  so  thoroughly  convinced  is  the  author 
of  this,  that  he  does  not  hesitate  to  say,  that  if  timely  precautions  were 
used,  there  would  not  be  one  decayed  tooth  where  there  are  now  a 
dozen. 


lEEEGULARITY    OF   THE   TEETH.  365 

Much  harm,  it  is  true,  may  be  done  by  improper  meddling  with  the 
teeth  during  this  period,  but  this,  so  far  from  inducing  a  total  neglect, 
should  only  make  those  having  the  care  of  children  more  solicitous 
in  securing  the  services  of  scientific,  accomplished  practitioners. 

For  the  judicious  management  of  second  dentition,  much  judg- 
ment and  a  correct  knowledge  of  the  normal  periods  of  the  erup- 
tion of  the  several  classes  of  teeth  are  required.  All  unnecessary 
interference  with  these  organs  at  this  early  period  of  life  should 
certainly  be  avoided,  as  it  will  only  tend  to  mar  the  perfection  at 
which  nature  ever  aims.  The  legitimate  duty  of  the  physician 
being,  as  Mr,  Bell  correctly  observes,  "the  regulation  of  the  natural 
functions  when  deranged,"  he  should  never  anticipate  the  removal 
by  nature  of  the  temporary  teeth,  unless  their  extraction  is  called 
for  by  some  pressing  emergency,  such  as  a  deviation  of  the  permanent 
ones  from  their  proper  place,  alveolar  abscess,  or  exfoliation  of  the 
alveolar  processes. 

The  mouth  should  be  frequently  examined  from  the  time  the  shed- 
ding of  the  deciduous  teeth  commences  until  the  completion  of  second 
dentition  ;  and  when  the  growth  of  the  permanent  teeth  so  far  outstrips 
the  destruction  of  the  roots  of  the  temporary,  that  the  former  are 
caused  to  take  an  improper  direction,  such  of  the  latter  as  have  occa- 
sioned the  obstruction  should  be  immediately  removed.  In  the  denti- 
tion of  the  upper  front  teeth  this  should  never  be  neglected;  for,  when 
they  come  out  behind  the  temporaries,  as  they  most  frequently  do,  and 
are  permitted  to  advance  so  far.  as  to  fall  on  the  inside  of  the  lower 
incisors,  a  permanent  obstacle  is  offered  to  their  subsequent  proper 
adjustment. 

When  a  wrong  direction  has  been  given  to  the  growth  of  the  lower 
front  teeth,  they  are  rarely  prevented  from  acquiring  their  proper 
arrangement  by  an  obstruction  of  this  sort.  They  should  not,  however, 
on  this  account  be  permitted  to  occupy  an  erroneous  position  too  long  ; 
for  the  evil  will  be  found  easier  of  correction  while  recent  than  after 
it  has  continued  for  a  considerable  length  of  time.  The  irregularity 
should  be  immediately  removed. 

The  permanent  central  incisors  of  the  upper  jaw  being  larger  than 
the  temporaries  of  the  same  class,  it  might,  thei-efore,  be  supposed  that 
the  aperture  formed  by  the  removal  of  the  one  would  not  be  sufficient 
for  the  admission  of  the  other,  without  an  increase  in  the  size  of  this 
part  of  the  maxillary  arch.  It  should  be  recollected,  however,  that 
by  the  time  these  teeth  usually  emerge  from  the  gums,  the  crowns  of 
the  temporary  lateral  incisors  are  so  much  loosened  by  the  partial 
destruction  of  their  roots,  as  to  yield  sufficiently  to  the  pressure  of  the 
former  to  permit  them  to  take  their  proper  position  within  the  dental 


366  DENTAL,   SURGERY. 

circle.  When  this  does  not  happen,  the  temporary  laterals  should  be 
extracted. 

Under  similar  circumstances,  the  same  course  should  be  pursued 
Avith  the  permanent  lateral  incisors  and  the  temporary  cuspids,  and 
also  with  the  permanent  cuspids  and  the  first  bicuspids. 

But  from  the  fact  that  the  bicuspids  are  erupted  before  the  perma- 
nent cuspids,  the  premature  extraction  of  the  temporary  cuspids  is 
often  the  cause  of  the  projection  of  one  or  more  of  the  front  teeth  ; 
sometimes  to  such  a  degree  as  to  produce  considerable  deformity. 

The  removal  of  the  temporary  cuspids  should  therefore  be  avoided 
when  there  is  reason  to  believe  that  the  growth  of  the  jaw  will  provide 
suflicient  space  for  a  deviating  permanent  lateral  incisor  to  take  a 
proper  position  within  the  dental  arch. 

The  bicuspids  being  situated  between  the  roots  of  the  temporary 
molars  are  seldom  caused  to  take  an  improper  direction  in  their  growth. 
Nor  are  they  often  prevented  from  coming  out  in  their  proper  place  for 
want  of  room. 

In  the  management  of  second  dentition  much  will  depend  on  the 
experience  and  judgment  of  the  practitioner.  If  he  be  properly  in- 
formed upon  the  subject,  and  gives  to  it  the  necessary  care  and  atten- 
tion, the  mouth  will,  in  most  instances,  be  furnished  with  a  healthful, 
well  arranged  and  beautiful  set  of  teeth.  At  this  time,  "  an  opportu- 
nity," says  Mr.  Fox,  "  presents  itself  for  effecting  this  desirable  object," 
(the  prevention  of  irregularity),  "  but  everythiag  depends  upon  a  cor- 
rect knowledge  of  the  time  when  a  tooth  requires  to  be  extracted,  and 
also  of  the  particular  tooth,  for  often  more  injury  is  occasioned  by  the 
removal  of  a  tooth  too  early  than  if  it  be  left  a  little  too  long ;  because 
a  new  tooth,  which  has  too  much  room  long  before  it  is  required,  will 
sometimes  take  a  direction  more  difficult  to  alter  than  a  slight  irregu- 
larity occasioned  by  an  obstruction  of  short  duration." 

The  temporary  teeth,  by  remaining  too  long  are  likely  to  affect  the 
arrangement,  and  consequently  the  health,  of  the  permanent  teeth,  and 
they  should  be  extracted,  because,  in  that  case,  their  presence  is  a  greater 
evil  than  any  that  would  be  occasioned  by  their  removal.  As  a  general 
rule,  they  should  be  suffered  to  remain  until  their  presence  is  likely  to 
injure  the  permanent  teeth  and  their  contiguous  parts. 

When  the  permanent  teeth  are  crowded,  the  lateral  pressure  is 
frequently  so  great  as  to  fracture  the  enamel.  If  this  cannot  be 
prevented  in  any  other  way,  one  on  each  side  should  be  extracted. 
It  is  better  to  sacrifice  two  than  permanently  to  endanger  the  health 
of  the  whole. 

The  file  or  revolving  discs  and  points  upon  the  dental  engine  should 
never  be  used  with  a  view  to  remedy  irregularity ;  the  extraction  of 


IRREGULARITY    OF    THE    TEETH.  367 

two  teeth,  one  on  each  side  of  the  jaw,  however  small  the  space  required 
to  be  gained  may  be,  is  far  preferable.  The  second  bicuspids,  cceteris 
paribus,  should  always  be  removed  rather  than  the  first,  but  sometimes 
the  extraction  of  the  first  becomes  necessary. 

By  the  removal  of  the  teeth,  ample  room  will  be  gained  for  the 
arrangement  of  all  the  remaining  ones,  and  the  injury  resulting  from 
a  crowded  condition  of  the  organs  prevented. 

The  author  does  not,  however,  wish  to  be  understood  as  conveying 
the  idea  that  filing  the  teeth  necessarily  causes  them  to  decay,  for, 
when  the  file  is  used  for  any  other  purpose  than  to  gain  room,  the 
apertures  may  be  made  large  enough  to  prevent  the  approximation 
of  the  organs,  and  thus  the  bad  effects  resulting  from  the  operation 
will  be  prevented. 

The  extraction  of  the  root  of  a  superior  front  tooth,  a  central  incisor, 
for  example,  when  the  crown  has  been  greatly  disfigured  or  wholly 
destroyed  by  mechanical  violence,  may  cause  the  superior  front  teeth 
to  fall  behind  the  inferior  teeth.  Should  such  a  deformity  not  occur, 
it  frequently  happens  that  an  unsightly  space  is  left,  too  small  for  the 
insertion  of  an  artificial  tooth  to  correspond  in  size  with  the  adjoining 
natural  ones. 

To  avoid  such  results,  the  root  should  be  allowed  to  remain,  and  the 
proper  treatment  instituted  to  subdue  the  inflammation,  the  pulp  re- 
moved when  exposed,  and  the  root  filled  to  the  apex  with  gold  or  other 
suitable  material.  By  pursuing  such  a  course,  the  root  is  retained 
until  such  a-time  as  its  removal  will  not  affect  the  adjoining  teeth.  In 
some  cases  the  portion  of  the  crown  destroyed  may  be  restored  with 
gold,  or  an  artificial  crown  inserted  on  a  pivot. 

When  the  deciduous  canines  are  extracted  on  the  approach  of  the 
permanent  lateral  incisors,  the  first  bicuspids  will  move  forward  and 
occupy  the  space  necessary  for  the  reception  of  the  permanent  canines, 
which  may  erupt  over  the  laterals,  and  by  their  pressure  cause  these 
latter  teeth  to  shut  within  the  lower  teeth. 

Fig.  125  illustrates  the  mischief  attending  the  premature  extraction 
of  the  deciduous  canines. 

Nature,  when  permitted  to  proceed  with  her  work  without  interrup- 
tion, is  able  to  perform  her  operations  in  a  perfect  and  harmonious 
manner.  But  the  functional  opera- 
tions of  all  the  parts  of  the  body  are 
liable  to  be  disturbed  from  an  almost 
innumerable  number  and  variety  of 
causes,  and  impairment  of  one  organ 
often  gives  rise  to  derangement  of 
the  whole  organism,  for  the  relief 


368  DENTAL  SUEGERY. 

of  which  the  interposition  of  art  not  unfrequently  becomes  necessary, 
and  it  is  fortunate  for  the  well-being  of  man  that  it  can  in  so  many 
instances  be  applied  with  success. 

In  sound  and  healthy  constitutions,  the  services  of  the  dentist  are 
seldom  required  to  assist  or  direct  second  dentition.  In  remarking  upon 
this  subject,  Dr.  Koecker  observes,  "that  the  children  for  whom  the 
assistance  of  the  dentist  is  most  frequently  sought  are  those  who  are  in 
a  delicate,  or  at  least  in  imperfect,  constitutional  health  ;  in  whom  the 
state  not  only  of  the  temporary  teeth,  but  of  the  permanent  also,  is  to 
be  considered ;  and  where  both  are  found  diseased,  the  future  health 
and  regularity  of  the  latter  require  the  greatest  consideration  of  the 
surgeon. 

"  Irregularity  of  the  teeth  is  one  of  their  chief  predisposing  causes 
of  disease,  and  never  fails,  even  in  the  most  healthy  constitutions,  to 
destroy,  sooner  or  later,  the  strongest  and  best  set  of  teeth,  unless  pro- 
perly attended  to.  It  is  thus  not  only  a  most  powerful  cause  of  destruc- 
tion to  the  health  and  beauty  of  the  teeth,  but  also  to  the  regularity 
and  pleasing  symmetry  of  the  features  of  the  face ;  always  producing, 
though  slowly  and  gradually,  some  irregularity,  and  not  unfrequently 
the  most  surprising  and  disgusting  appearance." 

Though  nature  is  generally  able  to  accomplish  the  task  assigned  her, 
yet  there  are  times  when  she  requires  aid,  and  it  is  then,  and  then  only, 
that  the  services  of  the  dentist  are  needed.  Therefore,  whilst,  on  the 
one  hand,  we  should  guard  against  any  uncalled  for  interference,  we 
should,  on  the  other,  always  be  ready  to  give  such  assistance  as  the 
nature  of  the  disturbance  presented  to  our  notice  may  require. 

The  progress  of  caries  in  the  temporary  teeth  is  very  rapid,  as  a 
general  rule,  owing  to  the  large  proportion  of  organic  matter  compared 
with  the  inorganic.  Alveolar  abscess  is,  therefore,  a  common  result  of 
the  loss  of  vitality,  and  the  absorption  of  the  alvfeolar  processes  from 
such  a  cause  may  expose  the  apex  of  the  root  of  one  or  more  temporary 
teeth. 

In  the  case  of  the  necrosed  roots  of  the  superior  incisors  presenting 
such  a  condition,  and  it  is  necessary  that  such  teeth  should  be  preserved 
in  order  to  prevent  an  irregular  arrangement  of  the  succeeding  perma- 
nent ones,  which  is  very  prone  to  occur  from  the  premature  loss  of  the 
temporary  teeth,  the  exposed  ends  of  the  roots  of  the  necrosed  tempo- 
rary teeth  may  be  excised  and  carefully  rounded  off  with  the  file  or 
corundum  point.  By  such  a  method  the  necrosed  teeth  may  be  retained 
in  the  mouth  until  the  period  of  shedding  has  arrived,  and  the  space 
necessary  for  the  reception  of  the  corresponding  permanent  teeth  be 
preserved. 

The  eruption  of  the  permanent  teeth  begins  before  any  of  the  tern- 


IRREGULAEITY   OF   THE   TEETH. 


369 


porary  teeth  ai-e  shed,  the  first  of  the  permanent  teeth  to  appear  being 
the  sixth-year  molars,  between  the  five  and  a  half  and  six  and  a  half 
years.  These  teeth  are  often  mistaken  for  temporary  teeth,  and  being 
prone  to  decay,  on  account  of  inflammation  of  structure,  and  the  early 
period  of  their  eruption,  they  are  frequently  lost  early  in  life.  But  as 
the  sixth-year  molars  perform  an  important  part  in  the  preservation 
of  the  integrity  of  the  arch,  their  retention  is  desirable  if  possible. 
Cases,  however,  occur  where  they  cannot  be  permanently  preserved, 
when  every  effort  should  be  made  to  preserve  them  up  to  a  certain 
period,  namely,  until  the  twelfth-year  molars  are  about  to  erupt,  or  until 
a  period  between  the  tenth  and  twelfth  years.     If  the  sixth-year  molars 

Fig.  126. 


Sixth  Year  3Iolar. 


are  lost  earlier  than  the  period  named,  the  adjoining  teeth  will  close 
up,  and  cause  irregularity  when  the  other  teeth  appear.  On  the  other 
hand,  if  the  sixth-year  molars  are  lost  later  than  the  time  named,  the 
space  they  occujDied  is  never  compactly  closed,  and  the  adjacent  teeth 
will  incline  toward  the  vacant  space,  and  the  continued  occlusion  in 
mastication  will  cause  them  to  tip  over  to  such  a  degree  as  to  result  in 
a  decided  impairment  of  the  occlusion.  Such  irregular  teeth  may  also 
become  painful  and  loose,  on  account  of  the  recession  of  the  gums  and 
the  absorption  of  the  alveolar  processes,  and  even  the  adjoining  teeth 
may  suffer  in  a  similar  manner. 

Fig.  126  represents  an  adult  lower  jaw,  side  view. 
24 


370  DENTAL  SUEGERY. 

Irregularity  of  Arrangement  of  the  Teeth. — The  causes  of  the  various 
forms  of  irregularity  of  the  teeth  are  divided  into  accidental — those 
occurring  after  the  eruption  of  the  teeth,  and  congenital — those  occur- 
ring prior  to  their  eruption. 

The  accidental  forms  of  irregularity  are  most  commonly  caused  by 
the  presence  of  temporary  teeth  beyond  the  proper  time  of  shedding, 
owing  to  the  process  of  absorption  of  their  roots  not  being  commen- 
surate with  the  development  of  the  permanent  teeth,  or  to  the  presence 
of  necrosed  roots  of  temporary  teeth  which  are  not  absorbed.  The 
congenital  forms  of  irregularity  are  generally  caused  by  a  want  of  de- 
velopment of  the  jaws  commensurate  with  the  size  of  the  teeth.  In 
some  rare  cases  the  excessive  development  of  the  maxillae  may  result 
in  abnormal  spaces  between  the  teeth. 

The  temporary  teeth  seldom  deviate  from  their  proper  place  in  the 
alveolar  arch  ;  but  irregularity  of  arrangement  is  of  frequent  occur- 
rence in  the  permanent  teeth,  especially  the  cuspids  and  incisors. 
The  first  and  second  molars  are  seldom  irregular ;  for,  like  the  teeth 
of  first  dentition,  they  rarely  encounter  obstruction  in  their  growth  and 
eruption.  The  sixth-year  molars  being  the  first  of  the  permanent  set 
to  appear,  the  ten  anterior  teeth  are  limited  to  that  part  of  the  arch 
occupied  by  the  ten  temporary  teeth ;  if  this  space  is  too  small,  irregu- 
larity must  of  necessity  ensue. 

The  dentes  sapientise  are  sometimes  irregularly  erupted,  in  conse- 
quence of  a  want  of  correspondence  between  the  development  of  the 
tooth  and  the  growth  of  the  maxilla.  The  tooth  in  such  cases  takes 
usually  the  direction  of  least  resistance,  the  crown  presenting  more  or 
less  obliquely  forward,  backward,  outward,  or  inward.  Of  these  four 
positions,  the  first  and  fourth  are  found  usually  in  the  lower  jaw  ;  the 
second  and  third  are  most  common  in  the  upper  jaw. 

When  a  bicuspid  is  forced  from  its  proper  place,  it  turns  inward 
toward  the  tongue,  or  outward  toward  the  cheek,  accordingly  as  it  is 
in  the  upper  or  lower  jaw;  or  it  may  be  so  turned  in  its  cavity  by  the 
occlusion  of  the  teeth  in  the  opposite  jaw,  the  loss  of  an  adjoining  tooth 
giving  the  necessary  space,  as  to  present  one  of  its  proximate  surfaces 
toward  the  cheek.  The  cuspids,  when  prevented  from  coming  out  in 
their  proper  place,  make  their  appearance  either  before  or  behind 
the  other  teeth.  AVhen  they  come  out  anteriorly,  which  they  do 
more  frequently  than  j^osteriorly,  they  often  become  a  source  of  annoy- 
ance to  the  upper  lip,  excoriating  and  sometimes  ulcerating  the  mucous 
membrane. 

The  incisors  of  the  upper  jaw  present  a  greater  variety  of  abnormal 
arrangement  than  any  of  the  other  teeth.  The  centrals  come  out 
sometimes  before  and  sometimes  behind  the  arch  ;  at  other  times,  their 


IREEGULARITY  OF  THE  TEETH. 


371 


median  sides  are  turned  either  directly  or  obliquely  forward  toward 
the  lip.  The  laterals  sometimes  appear  half  an  inch  behind  the  arch, 
looking  toward  the  roof  of  the  mouth ;  at  other  times  they  come  out 
in  front  of  the  arch,  and  at  other  times,  again,  they  are  turned  ob- 
liquely or  transversely  across  it. 

When  any  of  the  upper  incisors  are  transversely  inclined  toward  the 
interior  of  the  mouth,  the  lower  teeth,  at  each  occlusion  of  the  jaws, 
shut  before  them,  and  become  an  obstacle  to  their  adjustment.  This 
form  of  irregularity  often  interferes  with  the  lateral  motion  of  the  jaw. 

The  lower  incisors  sometimes  shut  in  this  manner,  even  when  there 
is  no  inward  deviation  of  the  upper  teeth.  In  this  case  the  irregularity 
is  owing  to  preternatural  elongation  of  the  lower  jaw,  which  arises 
more  frequently  from  some  fault  of  dentition  than  from  any  congen- 
ital defect  in  the  jaw  itself. 

Sometimes  the  superior  maxillary  arch  is  so  much  contracted,  and 
the  front  teeth  in  consequence  so  prominent,  that  the  upper  lip  is  pre- 
vented from  covering  them.  Cases  of  this  kind,  however,  are  rarely 
met  with  ;  but  when  they  do  occur,  it  occasions  much  deformity  of  the 
face,  and  forms  a  species  of  irregularity  very  difficult  to  correct. 
From  the  same  cause  the  Fig.  127. 

lateral  incisors  are  some- 
times forced  fi'om  the 
arch,  and  appear  behind 
the  centrals  and  cuspids, 
the  dental  •  circle  being 
filled  with  the  other  teeth. 

An  abnormal  promi- 
nence of  the  superior  in- 
cisors may  be  either  con- 
genital or  accidental, 
and  when  of  the  former 

origin   it    is   almost   in-      /  '  '  ^^^ 

variably  -accompanied 
with  a  contracted  arch, 
especially    between    the 


^wM 


bicuspids  of  the  right  and  left  sides  of  the  mouth,  the  incisors  occupy- 
ing a  V-shaped  position  (Fig.  127). 

When  this  form  of  irregularity  has  an  accidental  origin,  it  is 
generally  caused  by  a  pernicious  habit  of  thumb,  tongue,  or  artificial 
nipple  sucking.* 

*  Such  a  habit  as  thumb-sucking  may  be  prevented  by  the  application  of  some 
bitter  substance,  such  as  aloes,  to  the  thumb,  tying  the  arms  close  to  the  body 
at  night,  or  the  wearing  of  coarse,  heavy  gloves. 


372 


DENTAL   SURGERY. 


Figs.  128  and  129  represent  the  form  of  irregularity  caused  by 
thumb  sucking. 

An  unusual  prominence  of  the  superior  incisors,  attended  with  a 
diminution  of  space  between  the  bicuspids  and  an  abnormally  high 

vaulting  of  the  palate,  has 
been  thought  by  some  to 
be  very  common  to  con- 
genital idiots.  But  Drs. 
N.  W.  Kingsley  and  J. 
W.  White,  who  examined 
the  inmates  of  some  large 
institutions  for  the  care  of 
the  feeble-minded,  found 
that  such  a  defect  is  not 
an  invariable  rule,  as  only 
a  small  percentage  of  pro- 
nounced irregularity  in 
form  of  the  jaws,  or  ar- 
rangement of  the  teeth, 
and  that  generally  asso- 
ciated with  the  lowest  type 
of  idiocy,  was  common  to 
such  a  class  of  persons.. 

Tonsillitis  has  also  been 
named  by  Mr.  Tomes  as 
a  cause  for  a  contracted 
arch  between  the  opposite 
bicuspids,  the  labored 
breathing  from  the  filling 
up  of  the  fauces  by  the 
enlarged  tonsils,  with  the 
mouth  open,  causing  in- 
creased compression  of  the 
cheeks  over  the  lateral  parts  of  the  mouth,  while  the  median  portion 
escapes  the  controlling  pressure  which  would  be  exercised  when  the 
mouth  is  closed. 

Dr.  Kingsley  is  of  the  opinion  that  the  v-shaped  arch  is  nearly 
always  of  congenital  origin — that  is,  an  inherited  tendency,  while  the 
broad  or  rounded  form  of  arch  is  often  due  to  mechanical  causes. 

The  retention  in  the  jaw  of  permanent  teeth  is  also  a  cause  of  irregu- 
larity, as  in  some  cases  bicuspids  and  molars  may  not  erupt  sufficiently 
to  meet  the  opposing  teeth. 

There  are  many  other  deviations  in  the  arrangement  of  the  incisors. 


lEEEGULARITY  OF  THE  TEETH.  373 

Mr.  Fox  mentions  one  that  was  caused  by  the  presence  of  two  super- 
numerary teeth  of  a  conical  form,  situated  partly  behind  and  partly 
between  the  central  incisors,  Avhich,  in  consequence,  were  thrown  for- 
ward, while  the  laterals  were  placed  in  a  line  with  the  supernumeraries. 
The  central  incisors,  though  half  an  inch  apart,  formed  one  row,  and 
the  latei'als  and  supernumeraries  another.  Mr.  Fox  says  he  has  seen 
three  cases  of  this  kind.  This  description  of  irregularity  is  rarely 
met  with. 

M.  Delabarre  says  that  cases  of  transposition  of  the  germs  of  the  teeth 
occasionally  occur,  so  that  a  lateral  incisor  takes  the  place  of  a  central, 
and  a  central  the  place  of  a  lateral.  A  similar  transposition  of  a  cus- 
pid and  lateral  incisor  is,  also,  sometimes  seen.  Two  cases  of  this  sort 
have  fallen  under  the  observation  of  the  author. 

The  incisors  of  the  lower  jaw  being  smaller  than  those  of  the  upper, 
and  in  other  respects  less  conspicuous,  do  not  so  plainly  show  an  irreg- 
ularity in  their  arrangement,  nor  is  the  appearance  of  an  individual 
so  much  affected  by  it.  Still  it  should  be  guarded  against ;  for  such 
deviation,  whether  in  the  upper  or  lower  jaw,  may  prove  injurious  to 
the  health  of  the  teeth  and  the  beauty  of  the  mouth.  The  growth 
of  the  inferior  permanent  incisors  is  sometimes  more  rapid  than  the 
destruction  of  the  roots  of  the  corresponding  temporaries.  In  this 
case  the  former  emerge  from  the  gums  behind  the  latter,  and  some- 
times so  far  back  as  greatly  to  annoy  the  tongue  and  interfere  with 
enunciation.  At  other  times  the  permanent  centrals  are  prevented 
from  assuming  their  proper  place,  because  the  space  left  for  them  by 
the  temporaries  is  not  sufficient.  The  irregularity  in  the  former  of 
these  two  cases  is  greater  than  in  the  latter.  The  same  causes  in  like 
manner,  affect  the  laterals. 

M.  Delabarre  mentions  a  defect  in  the  natural  conformation  of  the 
jaws,  by  which  the  upper  temporary  incisors  on  one  side  of  the  median 
line  are  thrown  on  the  outside  of  the  lower  teeth,  while  the  corres- 
ponding teeth  on  the  other  side  of  the  same  line  fall  within.  The 
same  arrangement,  he  says,  may  be  expected,  unless  previously  reme- 
died, in  the  permanent  teeth.  The  author  has  met  with  but  two  cases 
of  this  sort,  and  the  subjects  of  these  he  did  not  see  until  after  they 
had  reached  maturity. 

Referring  to  an  ingrafted  tendency  in  all  living  matter  to  reproduce 
itself.  Dr.  Kingsley  remarks:  "  I  am  of  the  opinion  that  such  deformi- 
ties, even  when  transmitted  for  generations,  may  have  the  tendency 
stamped  out  by  being  corrected  immediately  on  their  development ; 
that  is,  before  the  deformity  has  made  its  fixed  impression  upon  the 
individual." 

Mr.  Mummery  is  of  the  opinion  that  a  large  amount  of  dental  dis- 


374  DENTAL  SUEGERY. 

ease  is  originated  by  overtaxing  the  brain  action  of  children,  and 
Dr.  Kingsley  remarks  that  "  the  next  generation  will  see  more  abnor- 
mality in  dental  development,  and  an  inci'ease  of  nervous  and  cerebral 
diseases,  and  that  the  two  are  correlated  and  spring  from  the  same 
cause." 

Treatment  of  Irregularity. — Orthodontia,  or  the  treatment  of  irreg- 
ularity, should  accord  with  the  indications  of  natui'e.  When  the 
irregularity  is  neither  great  nor  complicated,  and  its  causes  are  re- 
moved before  the  nineteenth  or  twentieth  year,  the  teeth,  without  the 
aid  of  art,  will,  in  many  cases,  assume  their  proper  position.  When, 
however,  the  efforts  of  the  economy  are  unavailing,  recourse  should  be 
had  to  the  dentist,  who  can,  in  most  instances,  bring  the  deviating 
organs  to  their  proper  position  in  the  arch.  The  general  rule  is,  that 
as  soon  after  the  eruption  of  a  tooth  as  it  becomes  certain  that  it  will 
assume  an  irregular  position,  interference  is  justifiable,  as  every  year 
not  only  increases  the  difficulties,  but  impairs  the  stability  of  the  den- 
tal organs.  Teeth  incline  to  return  to  their  place  on  the  removal  of 
the  cause  of  irregularity.  They  may  be  also  made  to  change  position 
under  the  influence  of  pressure.  The  pressure  must  be  constant ;  it 
must  be  sufficient  to  cause  motion,  yet  not  so  great  as  to  set  up  destruc- 
tive inflammation  ;  lastly,  it  must  be  continued  until  the  teeth  can  be 
kept  in  place  by  antagonism  with  the  opposing  teeth  ;  or  in  case  there 
is  no  such  antagonism,  a  retaining  appliance  niust  be  worn  more  or 
less  constantly  for  a  year,  or  even  longer.  The  regulating  appliance 
should  be  as  simple  in  its  construction  as  is  possible  to  accomplish  the 
purpose,  so  that  both  time  and  labor  may  be  saved,  and  the  patient  be 
able  to  attend  to  its  removal  and  adjustment  when  it  becomes  necessary 
to  cleanse  it ;  this  should  frequently  be  done. 

Teeth  artificially  regulated  change  position  chiefly,  if  not  entirely, 
by  the  double  process  of  absorption  from  one  side  of  the  socket,  fol- 
lowed by  the  slower  process  of  ossific  deposit  on  the  opposite  side.  It 
is  therefore  essential  to  success  that  the  tooth  be  retained  in  its  new 
position,  either  by  the  other  teeth  or  by  mechanical  appliance,  until 
such  deposit  is  formed.  Many  cases  fail  from  a  want  of  persistence  on 
the  part  of  patient  or  dentist. 

How  far,  and  in  what  direction  a  tooth  may  be  moved,  will  depend 
partly  upon  the  position  of  the  apex  of  the  root ;  partly  upon  the 
antagonism  of  the  opposing  teeth. 

Cuspids  growing  out  far  upon  the  alveolar  arch  will  usually  be 
found  to  have  short  and  curved  roots.  The  attempt  to  move  them 
might  cause  the  curved  apex  to  pierce  the  alveolus.  Even  when  not 
curved,  the  root  is  short,  and  the  regulated  tooth  will  not  possess  that 
durability  which  is  characteristic  of  the  cuspids.     It  should  always  be 


IRREGULARITY   OF   THE    TEETH.  375 

b  )rne  in  mind  that  in  regulating  teeth  the  crown  is  the  movable 
point,  whilst  the  apex  of  the  root  is  the  fixed  point,  and  must  deter- 
mine in  great  degree  the  extent  and  direction  of  motion. 

Again,  the  natural  or  artificial  movement  of  bicuspids  backward  to 
make  room  for  front  teeth  may  be  aided  or  hindered  by  the  opposing 
teeth.  An  upper  bicuspid,  for  instance,  once  carried  back,  so  that  the 
posterior  slope  of  the  lower  bicuspid  strikes  it,  w^ill  retain  its  position 
or  may  be  thrown  even  further  back. 

Upper  incisors  striking  inside  the  lower,  or  lower  incisors  unnatu- 
rally prominent,  may  be  regulated,  and  the  opposing  teeth  -will  tend  to 
keep  them  in  their  corrected  position.  But  it  will  require  long  and 
patient  use  of  the  regulating  apparatus  to  keep  in  place  upper  incisors 
which  project  outward,  or  lower  incisors  inclining  inward. 

In  deciding  upon  the  removal  or  extraction  of  an  irregular  tooth,  it 
should  not  be  forgotten  that  a  tooth  moved  by  mechanical  appliance, 
especially  if  the  change  in  position  is  considerable,  will  not  prove  as 
durable  as  if  no  movement  had  been  necessary.  Hence  it  may  some- 
times be  advisable  to  extract  irregular  cuspids  in  cases  where  their 
correction  requires  much  change  in  their  position  and  that  of  the 
bicuspids,  and  the  arch  is  completely  and  regularlj^  filled  by  the 
remaining  teeth. 

In  a  case  presented  to  the  late  Prof.  Austen,  the  superior  arch 
was  perfectly  regular  and  closely  filled ;  but  both  cuspids  had  come 
out  above  the  arch.  The  cuspid  roots  were  normal,  and  it  seemed 
practicable  ■  to  bring  these  teeth  down  into  the  places  of  the  first 
bicuspids.  But  the  four  bicuspids  were  sound,  and  the  first  bicuspids 
gave  very  much  the  appearance  of  the  natural  arrangement.  Hence, 
as  in  point  of  expression  there  would  be  no  great  gain,  and  in  point 
of  durability  a  probable  loss,  it  was  not  thought  advisable  to  subject 
the  patient  to  the  tedious  annoyance  of  regulation. 

In  describing  the  treatment  of  irregularity,  we  shall  notice  the  means 
by  which  some  of  its  principal  varieties  may  be  remedied  ;  otherwise, 
the  application  of  the  principles  of  treatment  would  not  be  well 
understood,  since  it  must  be  varied  to  suit  each  individual  case. 

As  a  general  rule,  the  sooner  irregularity  in  the  arrangement  of  the 
teeth  is  remedied  the  better  ;  for  the  longer  a  tooth  is  allowed  to  occupy 
a  wrong  position,  the  more  difficult  will  be  its  adjustment.  The 
position  of  a  tooth  may  sometimes  be  altered  after  the  eighteenth, 
twentieth,  or  even  the  thirtieth  year ;  but  it  is  better  not  to  delay  the 
application  of  the  proper  means  until  so  late  a  period.  A  change  of 
this  kind  may  be  much  more  easily  effected  before  the  several  parts 
of  the  osseous  system  have  reached  their  full  development,  and  while 
the  formative  process  is  in  vigorous  operation,  than  at  a  later  j^eriod 


376  DENTAL   SUEGERY. 

of  life.  The  age  of  the  subject,  therefore,  should  always  govern  the 
practitioner  in  forming  an  opinion  as  to  the  practicability  of  correcting 
irregularity.  Previously  to  the  twentieth  year,  the  worst  varieties  of 
irregularity  may,  in  most  cases,  be  successfully  treated. 

The  first  thing  claiming  attention  in  the  treatment  is  the  removal 
of  its  causes.  Whenever,  therefore,  the  presence  of  any  of  the  tem- 
porary teeth  has  given  a  false  direction  to  one  or  more  of  the  perma- 
nent, they  should,  as  a  general  rule,  be  extracted,  and  the  deviating 
teeth  pressed  several  times  a  day  with  the  finger,  in  the  direction 
they  are  to  be  moved.  This,  if  the  irregularity  has  been  occasioned 
by  the  presence  of  a  deciduous  tooth,  will,  generally,  be  all  that  is 
required. 

But  when  it  is  the  result  of  narrowness  of  the  jaw,  either  congenital 
or  acquired,  a  permanent  tooth  on  either  side  should  be  removed,  to 
make  room  for  such  as  are  improperly  situated.  All  the  teeth  being 
sound  and  well  formed,  the  second  bicuspids  are  the  teeth  which  should 
be  extracted  ;  but  if,  as  is  often  the  case,  the  first  permanent  molars 
are  so  much  decayed  as  to  render  their  preservation  impracticable,  or, 
at  least,  doubtful,  these  teeth  should  be  removed  in  their  stead.  After 
the  removal  of  the  second  bicuspids,  the  first,  usually,  very  soon  fall 
back  into  the  places  which  they  occupied,  and  furnish  ample  room  for 
the  cuspids  and  incisors.  But  if  they  fail  to  do  this,  they  may  be 
gradually  forced  back  by  inserting  wedges  of  wood  or  rubber  between 
them  and  the  cuspids,  or  by  means  of  a  ligature  of  silk,  or  rubber, 
securely  fastened  to  the  first  molar  on  each  side,  or  by  other  proper 
appliances.  These  should  be  renewed  every  day,  until  the  desired 
result  is  produced. 

The  most  frequent  kind  of  irregularity,  resulting  from  narrowness 
of  the  jaw,  is  the  prominence  of  the  cuspids.  These  teeth,  with  the 
exception  of  the  second  and  third  molars,  are  the  last  of  the  teeth  of 
second  dentition  to  be  erupted  ;  consequently  they  are  more  liable  to 
be  forced  out  of  the  arch  than  any  others,  especially  when  it  is  so 
much  contracted  as  to  be  almost  entirely  filled  before  they  make  their 
appearance.  The  common  practice  in  such  cases  was  to  remove  the 
projecting  teeth.  But  as  the  cuspids  contribute  more  than  any  of  the 
other  teeth,  except  the  incisors,  to  the  beauty  of  the  mouth,  and  can, 
in  almost  every  case,  be  brought  to  their  proper  place,  the  practice  is 
injudicious.  Instead  of  removing  these,  a  bicuspid  should  be  extracted 
from  each  side.  When  the  space  between  the  lateral  incisor  and  the 
bicuspid  is  equal  to  one-half  the  width  of  the  crown  of  the  cuspid, 
the  second  bicuspid  should  be  removed,  but  when  it  is  less,  the  first 
should  be  taken  out ;  because,  although  the  crown  of  the  latter  may 
be  carried  far  enough  back  after  the  removal  of  the  former  to  admit 


lEEEGULARITY   OF   THE   TEETH.  377 

tlie  crown  of  the  cuspid  between  it  and  the  lateral  incisor,  the  root 
of  this  tooth  will  remain  in  front  and  partly  across  the  root  of  the  first 
bicuspid ;  leaving  a  more  or  less  prominent  vertical  ridge  on  the 
anterior  part  of  the  alveolar  border,  which,  to  some  extent  at  least, 
acts  as  an  irritant  to  the  gums  and  periosteum. 

As  the  incisors  of  the  upper  jaw  are  more  conspicuous  than  those 
of  the  lower,  and  when  well  arranged  contribute  more  to  the  beauty 
of  the  mouth,  their  preservation  and  regularity  are  of  greater  relative 
importance.  Hence,  the  removal  of  a  lateral  incisor,  when  it  is  situ- 
ated behind  the  dental  arch,  as  is  often  done  with  a  view  to  remedy 
the  deformity  produced  by  false  position,  is  a  practice  which  cannot  be 
too  strongly  deprecated,  provided  sufficient  space  can  be  made  for  it 
between  the  cuspid  and  central  incisor  by  the  removal  of  a  bicuspid 
from  each  side  of  the  jaw. 

Dr.  Kingsley  remarks  that  "  cases  are  of  frequent  occurrence  which 
show  that  a  pair  of  any  of  the  teeth  in  the  mouth  may  be  removed  to 
correct  an  irregularity,  excepting  the  canines  of  both  jaws  and  the 
superior  central  incisors."  It  would  be  an  inconceivable  case  which 
would  justify  the  extraction  of  the  superior  central  incisors ;  but  the 
upper  lateral  incisors  and  any  pair  of  the  lower  incisors  may  be 
removed,  in  certain  cases,  without  any  serious  detriment  to  the  appear- 
ance of  the  mouth."  "  It  is  not  necessary  to  the  contour,  symmetry, 
or  harmony  of  the  features  that  every  one  of  the  masticating  organs 
should  be  retained  in  the  mouth."  "  The  articulation  of  masticating 
organs  is  of  much  more  importance  than  their  number,  and  a  limited 
number  of  grinding  teeth  fitting  closely  on  occlusion  will  be  of  far 
greater  benefit  to  the  individual  than  a  mouthful  of  teeth  with  the 
articulation  disturbed."  "  It  is  a  disputed  point  as  to  which  of  the 
teeth  behind  the  six  front  teeth  can  be  best  spared  from  the  mouth." 
"  If  the  sixth-year  molars  are  badly  decayed,  their  removal  would  be 
indicated.  If  they  were  sound,  and  also  the  bicuspids,  there  might  be 
no  greater  reason  for  their  removal  than  either  of  the  bicuspids.  In 
fact,  sound  molars  in  the  jaw  are  of  more  value  as  masticating  organs 
than  equally  sound  bicuspids."  The  same  writer  is  also  of  the 
opinion  that  extraction  of  any  teeth  from  a  v-shaped  jaw  before  it  is 
widened,  would  be  likely  to  prove  bad  practice. 

Many  different  forms  of  appliances  are  necessary  in  correcting  an 
irregular  arrangement  of  the  teeth,  as  almost  every  case  presents  its 
own  peculiarities.  It  is  therefore  not  only  impossible  to  describe  every 
form  of  irregularity  to  which  the  teeth  are  subject,  but  also  the  forms 
of  appliances  necessary.  The  attention  of  the  reader  will,  therefore, 
be  directed  to  the  treatment  of  the  most  common  forms,  and  the 
necessary  appliances  for  their  correction,  modifications  of  which  can 


378 


DENTAL  SURGERY. 


be  constructed  according  to  the  peculiarities  presenting  themselves. 
The  most  simple  appliances  for  correcting  irregularity  consist  of 
rings  cut  from  rubber-tubing,  and  silk  or  rubber  ligatures,  which  have 
their  uses  in  the  management  of  some  of  the  easily  manipulated  casts. 
The  value  of  such  simple  appliances,  however,  depends  upon  the 
skill  exercised  in  applying  and  securing  them.  A  simple  band  or  ring 
cut  from  rubber-tubing,  and  prevented  from  slipping  up  to  and  in- 
juring the  gum,  by  means  of  waxed  floss-silk  tightly  tied  about  the 
necks  of  the  teeth,  will  answer  for  drawing  two  teeth,  incisors  for  ex- 
ample, together,  between  which  there  is  an  unsightly  space.  A  similar 
ring  may  be  employed  for  correcting  an  irregular  front  tooth  which 
projects  beyond  the  arch. 

The  following  figures  represent  some 
of  the  most  useful  knots  for  applying  silk 
ligatures : — 

Fig.  130  represents  13  forms  of  the 
most  useful  knots:  J,  thumb-knot;  2, 
(12,  15,  16),  various  stages  of  the  clove- 
hitch  ;  8,  drag-rope,  or  lever-hitch ;  4, 
draw-knot ;  5,  garrick  bend  ;  6,  common 
or  sheet-bend  ;  7,  running-knot ;  9,  men's 
harness-hitch;  10,  sheep-shank  ;  11,  dou- 
ble bowline-knot ;  12,  first  stage  of  clove- 
hitch  ;  13,  single  bowline-knot ;  14,  half- 
hitch  ;  15,  second  stage  of  clove-hitch. 

In  describing  the  treatment  of  irregu- 
larity, we  shall  commence  with  an  incisor 
occupying  an  oblique  or  transverse  posi- 
tion across  the  alveolar  ridge  ;  so  that  the 
cutting  edge  of  the  tooth,  instead  of  being 
in  a  line  with  the  arch,  forms  an  angle 
with  it  of  from  forty  to  ninety  degrees. 
This  variety  of  deviation  is  rarely  met 
with  in  both  centrals,  but  often  occurs 
with  one.  Some  dentists  have  recom- 
mended in  cases  of  this  kind,  when  the 
space  between  the  adjoining  central  and 
lateral  incisor  is  equal  to  the  width  of 
the  deviating  tooth,  to  turn  the  latter  in 
its  socket  with  a  pair  of  forceps,  or  to  extract  and  immediately  re- 
place it  in  its  proper  position.  It  is  scarcely  necessary  to  say  that  if 
a  tooth  is  turned  in  its  socket,  without  great  care  is  exercised  and  the 
operation  gradually  performed,  the  vessels  and  nerves  from  which  it 


IRREGULARITY   OF   THE   TEETH. 


;79 


derives  nourishment  and  vitality  are  strangulated  ;  hence.,  though  its 
connection  with  the  alveolus  may  be  partially  re-established,  it  will  be 
liable  to  act  as  a  morbid  irritant,  and  be  subject  to  inflammation  from 
comparatively  slight  causes. 

The  tooth,  however,  may  be  brought  to  its  proper  position,  with- 
out incurring  the  risk  of  injury,  by  accurately  fitting  a  gold  ring 
or  band,  with  knobs  on  the  labial  and  palatine  sides ;  to  each  of 
these  a  ligature  should  be  attached.  Thus  fastened  to  the  ring, 
each  end  should  be  carried  back,  one  on  either  side,  in  front 
and  behind  the  arch,  and  secured  to  the  bicuspids  as  represented 
in  Fig.  131,  so  as  to  act  constantly  upon  the  irregular  tooth.  The 
ligatures  should  be  renewed  from  day  to  day,  until  the  tooth  assumes 
its  proper  position.  Should  the  space  not  be  sufficient  to  permit  the 
use  of  the  band,  the  method  practiced  by  Mr.  Tomes,  is  shown  in 
Fig.  132.  A  plate  is  fitted  to  the  inside  of  the  arch,  and  a  band 
carried  in  front  and  soldered   to  projections  from  the  plate,  which 


Fig.  131. 


Fig.  132. 


pass  between  the  bicuspids.  On  each  side  of  the  irregular  tooth  a 
metallic  dovetail  is  fastened,  and  pieces  of  compressed  wood  inserted 
into  them.  The  swelling  of  the  wood  gradually  turns  the  tooth. 
In  a  few  days  the  metal  sockets  will  require  to  be  changed  in  position, 
and  in  a  few  weeks  the  tooth  may  be  thus  brought  nearly  or  quite  to 
its  natural  place. 

If* the  space  permits,  these  two  methods  may  be  advantageously 
combined.  Use  the  plate  as  in  Fig.  132,  with  the  inner  dovetail ; 
but  for  the  long  outside  band  substitute  the  band  (Fig.  131)  around 
the  tooth,  with  a  loop  on  the  median  side ;  from  this  pass  an 
elastic  ligature  to  a  hook  soldered  on  the  plate.  The  tooth  is 
turned  on  its  axis  by  the  combined  pull  of  the  ligature  and  thrust 
of  the  wood. 

For  turning  or  twisting  a  tooth  upon  its  axis.  Dr.  J.  F.  Flagg, 
recommends  the  clove-hitch,  Fig.  130 ",  over  which  the  tnds  of  the 


380 


DENTAL   SURGERY. 


ligatures  are  passed  and  then  tied  tightly  with  a  surgeon's  knot,  which 
holds  so  firmly  to  the  tooth  that  it  will  not  slip;  the  ends  are  then 
carried  to  a  rubber  ring  attached  to  a  neighboring  tooth,  and  by  its 
elasticity  keeps  up  a  constant  torsion  force. 

pjg    233  For  rotating  a  single  tooth  as  well  as 

drawing  out  teeth  that  incline  within 
the  arch,  the  screws  represented  in  Fig, 
133,  and  designed  by  Dr.  Farrar,  will 
be  found  as  useful  as  any  other  means. 
Before  attempting  to  turn  the  devi- 
ating organ,  it  should  be  ascertained  if  the  aperture  between  the 
adjoining  teeth  is  sufiicient  to  admit  of  the  operation.  If  not,  it  should 
be  increased  by  the  extraction  of  a  bicuspid  from  each  side  of  the  jaw, 
and  moving  the  teeth  in  front  of  them  backward  until  sufiicient  room 
is  obtained.  The  time  required  to  do  this  will  vary  from  three  to  eight 
or  ten  weeks,  depending  upon  the  number  of  teeth  to  be  acted  on,  and 
the  age  of  the  patient.  A  sufficient  space  may  sometimes  be  gained  by 
pressing  outward  the  adjoining  teeth  in  cases  where  they  fall  within 
the  normal  curve  of  the  arch.  This  may  be  done  by  the  expansion 
of  wood  or  rubber,  contained  in  metal  sockets  attached  to  the  plate, 
behind  each  tooth  to  be  moved. 


Fig.  134. 


Fig.  135. 


Fig.  136. 


Figs.  134,  135  and  136  represent  favorite  devices  of  Dr.  J.  N. 
Farrar  for  rotating  teeth,  the  simplicity  of  which  requires  no  further 
explanation  except  that  it  is  constructed  entirely  of  gold  or  platinum, 
and  bound  upon  the  tooth  to  be  rotated  by  a  slip-noose  as  thin  as 
writing  paper,  and  about  one-twelfth  to  one-fifteenth  of  an  inch  wide, 
which  is  tightened  by  means  of  a  nut  screwed  against  a  small  strip  of 
plate,  resting  against  other  teeth. 

Irregular  and  protruding  front  teeth  may  be  partially  rotated  and 
drawn  into  position  by  a  very  simple,  but  at  the  same  time  ingenious 
appliance  devised  by  Dr.  S.  H.  Guilford.  Figs.  137, 138, 139,  140  and 
141  represent  two  cases  of  the  kind  referred  to,  and  Dr.  Guilford's 


IRREGULARITY    OF    THE   TEETH. 

Fig.  138. 


381 


appliance.  According  to  Dr. 
Guilford's  description,  this  ap- 
pliance is  made  on  a  model  of 
the  teeth,  and  is  constructed 
as  follows:  "A  piece  of  gold 
tacking  cut  an  eighth  of  an 
inch  wide,  and  of  sufficient 
length  to  extend  along  and  a 
trifle  beyond  the  palatal  sur- 
faces of  the  centrals,  is  bent 
to  conform  as  closely  as  possi- 
ble to  the  lingual  surfaces  of 
these  teeth,  and  forward  so  as 
to  slightly  clasp  the  disto- 
palatal  angles,  as  shown  in  a, 
Fig.  139.  To  this  are  solderec 
two  strips  cut  from  upper ' 
plate  scrap,  a  little,  narrower 
than  the  first  piece,  and  bent  in  the  form  of  b,  and  c,  Fig.  139,  re- 
spectively, which  are  sufficiently  long  to  extend  slightly  over  the  ante- 
rior and  posterior  surfaces  of  the  teeth.  After  being  properly  shaped 
to  fit  the  model,  their  backs  are  soldered  together,  and,  in  turn,  soldered 
to  the  part  (a),  as  shown  in  Fig.  139.  The  only  thing  then  to  be  done 
is  to  reduce  with  a  file  the  thickness  of  the  part  b,  c,  which  passes  be- 
tween the  teeth.  Fig.  140.  Before  applying  such  a  fixture,  it  may  be 
necessary  to  place  a  piece  of  wood  between  the  teeth  for  a  few  hours, 
to  separate  them  sufficiently  to  admit  the  appliance.  The  labial  part 
of  the  apparatus  should  rest  against  the  teeth  just  at,  or  slightly  above 


382 


DENTAL  SUEGERY. 


the  most  prominent  part  of  their  convexity ;  while  the  lingual  portion 
should  be  near  the  gum  (not  quite  touching  it),  and  the  slightly  curved 
ends  of  this  part  will  catch  just  above  the  little  nodule  usually  found 
on  the  disto-palatal  angle  near  the  gum.  When  thus  secured  it  cannot 
easily  be  displaced  by  the  action  of  the  lip  or  tongue.  Bend  the  long 
palatal  arms  slightly  toward  the  short  labial  ones  daily,  and  spring 
it  back  into  position  on  the  teeth.  The  elasticity  of  the  gold 
stiffened  by  the  solder  will  do  the  work.  To  guard  against  its  acci- 
dental loosening,  tie  it  to  the  tooth  with  a  thread." 

Fig.   142  represents  an  appliance  designed  by  Dr.   Kiugsley  for 
twisting  the  central  incisors.    After  the  arch  was  expanded,  as  it  was  a 
P      -,^9  case  of  contracted  arch,  a  vul- 

canite plate  was  required  to 
retain  the  teeth  in  their  spread 
condition,  and  its  presence  was 
made  available  for  attach- 
ments for  elastic  ligatures.  A 
small  hook  of  gold  wire  was 
inserted  opposite  the  canine 
teeth,  and  a  little  staple  or 
loojD  of  the  same  wire  at  the 
apex  of  the  plate  between  the 
centrals.  Previous  to  inser- 
tion a  ring  of  rubber  cut 
from  tubing  was  caught  over 
one  hook,  passed  through  the  loop  at  the  apex  and  caught  on  to  the 
other  hook.  The  plate  was  then  introduced  into  the  mouth,  and  the 
elastic  band  drawn  over  each  lateral  incisor,  as  seen  in  the  figure.  The 
tendency  of  the  elastic  band  to  contract  in  a  straight  line,  operated  only 

on  the  inverted  corners  of 
the  centrals,  and  by  this 
means  the  centrals  were 
turned  into  their  proper 
positions. 

Figs.  143  and  144  rep- 
resent a  case  of  irregu- 
larity before  and  after 
treatment,  where  the  over- 
lapping central  incisors 
were  turned,  and  a  devi- 
ating lateral  incisor  forced 
Outward,  by  the  appliances 
just  described. 


Fig.  143. 


IRREGULARITY    OF    THE   TEETH. 


383 


The  operation  known  as  "  torsion,"  which  has  been  recommended 
by  Mr.  Tomes,  consists  in  forcibly  turning  a  tooth  in  its  cavity  by 
grasping  it  near  its  neck  with  a  pair  of  forceps,  the  beaks  of  which 
are  guarded  with  chamois-skin  or  other  substance,  to  prevent  injury. 
Where  the  deviating  tooth,  such  as  an  incisor,  requires  but  one- 
fourth  of  a  turn  or  twist,  or  less,  this  is  accomplished  by  one  ope- 
ration ;  but  where  one-half  p^^  ^^^ 
turn  is  required,  several 
operations,  after  intervals 
of  a  few  days,  are  necessary. 
The  tooth  is  then  secured 
in  its  new  position  by 
means  of  ligatures  until 
a  retaining  plate  is  con- 
structed, and  the  necessary 
antiphlogistic  treatment 
pursued.  The  danger  of 
such  an  operation  as  torsion 
is  the  injury  likely  to  occur 
to  the  vessels  and  nerves, 
resulting  in  devitalization,  and  in  no  ease  should  it  be  attempted  until 
the  root  of  the  deviating  tooth  is  fully  formed,  and  sufficient  space 
exists  for  its  reception. 

The  use  of  vulcanized  India-rubber  is  of  great  value  in  the  correc- 
tion of  irregularities.  The  peculiar  manipulations  it  requires  will  be 
found  in  another  portion  of  this  w^ork  ;  it  is  only  necessary,  therefore, 
in  concluding  this  chapter,  to  briefly  mention  the  properties  which  fit 
it  for  this  important  branch  of  dental  practice. 

It  admits  of  absolutely  perfect  adaptation  to  the  teeth.  If  only  a 
part  of  the  crowns  of  the  teeth  require  fitting,  a  wax  impression  will 
be  sufficiently  accurate.  But  if  the  gum  and  under-cut  surfaces  of  the 
teeth  are  to  be  fitted,  a  plaster  impression  is  necessary.  Prof  Austen's 
method  of  taking  plaster  impressions  in  gutta-percha  cups  Avill  enable 
a  skillful  operator  to  take  an  accurate  impression  of  any  mouth,  how- 
ever irregularly  the  teeth  may  be  arranged. 

A  closely-fitting  vulcanite  plate  can  be  Avorn  with  comfort ;  hence 
the  patient  is  not  tempted  to  remove  it.  It  has  no  motion;  hence  does 
not  wear  the  teeth  or  irritate  the  gums.  Its  firmness  of  adaptation 
makes  it  an  excellent  "fixed  point,"  from  which  to  make  pressure  or 
traction  in  any  required  direction  upon  the  irregular  teeth  ;  the  counter- 
pressure,  being  distributed  all  over  the  regular  teeth,  is  not  felt.  When 
it  is  necessary  to  cap  the  molars,  a  layer  of  varying  thickness  should 
be  carried  over  them  all,  to  prevent  the  soreness  caused  by  mastication 
upon  any  one  tooth. 


384 


DENTAL   SURGERY. 


Any  variety  of  appliance  may  be  used  in  connection  with  the  plate 
that  the  judgment  of  the  operator  suggests  as  best  adapted  to  bring 
about  the  required  change.  The  plastic  nature  of  the  crude  material 
permits  enlargement  or  extension  in  any  direction,  without  the  neces- 
sity of  soldering,  as  in  metallic  plates,  and  with  sufficient  exactness. 

Thus,  prominences  may  be  left  behind  teeth  which  are  to  be  moved 
outward,  in  which  may  be  made  dovetails  for  the  insertion  of  com- 
pressed wood  ;  slits  or  holes  for  India-rubber,  which  makes  more  rapid 
pressure  than  the  wood ;  or  holes  for  the  insertion  of  small  screws. 
These  screws  may  bear  directly  against  the  tooth,  and  be  turned 
slightly  each  day  or  two.  Or  the  portion  of  the  plate  next  the  tooth 
or  teeth  to  be  moved  may  be  separated  with  a  delicate  saw  from  the 
plate ;  the  ends  of  the  screw  or  screws  playing  into  this  move  the  tooth 
or  teeth  by  a  broad  bearing,  which  will,  in  certain  cases,  be  better  than 
the  point  of  the  screw. 

Or  a  small  piece  of  vulcanized  rubber  may  be  taken  ;  one  end  jBtting 
against  a  molar  or  bicuspid,  and  into  the  other  end  a  screw  thread  cut 
to  receive  a  delicate  screw ;  on  the  head  of  this  screw  a  second  piece 
of  rubber  may  be  fitted  against  the  tooth,  to  be  moved  so  as  to  allow 
the  screw  to  be  turned  without  changing  its  position  on  the  tooth. 
This  combination  forms  a  miniature  jack-screw,  similar  to  those  recom- 
mended some  years  since  by  Dr.  Dwindle,  and  will  often  be  found 
useful.  It  may  be  used  in  combination  with  the  rubber  plate  by  attach- 
ing one  end  to  the  plate  instead  of  resting  it  against  a  tooth. 

If  it  is  desired  to  move  a  tooth  by  the  elasticity  of  a  spring,  this  can 
be  made  of  vulcanite  ;  one  end  of  it  fitting  tightly  into  a  groove  cut  in 
the  plate,  so  that  the  free  end  shall  bear  with  the  requisite  force 
against  the  tooth.     The  elastic   slip  or  spring  can  readily  be  bent  by 

means  of  a  warm  burnisher,  so  as  to 
press  with  greater  or  less  force,  as  the 
case  may  demand.  Fig.  145,  taken 
from  Mr.  Tomes'  work,  will  illustrate 
one  variety  of  the  application  of  metal 
springs  on  a  vulcanite  plate;  in  this 
case  pressing  outward  and  laterally 
the  left  central  and  right  lateral  incis- 
ors. This  mode  of  making  pressure 
will  be  found  very  useful.  It  acts 
steadily,  is  under  control,  and  does  not 
need  renewal  so  often  as  the  wedges 
of  wood  or  rubber. 

Where  ligatures  are  required,  the 
vulcanite  plate  affords  an  easy  means 
of  attaching  them  in  any  desired  position ;  passing  them  through  holes 


Fig.   145. 


IRREGULARITY   OF   THE   TEETH. 


385 


and  tying;  looping  them  over  projecting  knobs  of  vulcanite,  or  over 
small  metal  hooks  set  in  the  plate ;  or  stretching  them  through  slits 
sawn  in  the  plate. 

If  a  band  is  to  be  carried  for  any  purpose  in  frontof  the  arch,  it  may 
be  connected  with  the  plate  on  the  inside  of  the  arch,  through  any  spaces 
occurring  between  the  bicuspids  or  molars  ;  if  there  are  no  such  spaces, 
or  if  they  ai-e  to  be  closed  up  in  the  process  of  regulation,  the  cap 
which  is  often  required  to  pass  over  the  molars  will  connect  the  two. 
But  the  outside  band  is  not  often  necessary.  The  inside  plate  is  less 
awkwai'd  to  the  patient;  it  is  out  of  sight;  and  almost,  if  not  quite 
every  required  movement  can  be  obtained  from  it. 

Where  the  irregularity  consists  in  some  of  the  teeth  projecting  while 
others  incline  inward,  such  a  case  can  be  advantageously  treated  by 
the  use  of  a  vulcanite  plate ;  the  various  stages  progressing  nearly  at 
the  same  time.  The  impression  in  this  case  to  be  taken  in  plaster ; 
the  plate  capping  the  second  molars ;  first  molars  and  first  bicuspids 
carried  outward  by  wooden  or  elastic  wedges,  or  by  a  double  spring  of 
vulcanite  fastened  to  the  plate  opposite  each  space  of  the  extracted 
second  bicuspids  ;  £he  left  central  and  right  lateral  carried  out  by 
wedges  or  screws ;  the  right  central  and  left  lateral  brought  in  by  liga- 
tures looped  over  hooks  in  the  plate.  At  the  completion  of  the  work  a 
new  impression  to  be  taken,  and  the  plate  worn  until  the  teeth  become 
firmly  fixed  ;  the  use  of  a  retain- 
ing plate  preventing  a  return  of 
the  teeth  to  their  old  positions. 

Ligatures  in  connection  with 
a  vulcanite  plate  can  also  be 
employed  for  drawing  irregular 
projecting  front  teeth  to  their 
normal  positions,  after  the  re- 
moval of  posterior  teeth  (the 
second  right  and  left  bicuspids, 
for  example),  to  afford  the  requi- 
site space.  Fig.  146  represents  a 
case  of  torsion  and  retraction  of 

the  central  incisors,  with  pins  imbedded  in  the  vulcanite  plate  for  the 
attachment  of  the  ends  of  the  ligature. 

The  late  Prof.  J.  H.  McQuillen  recommended  a  strip  of  thick  gold 
plate,  similar  to  what  is  used  for  clasps,  and  curved  to  suit  the  arch, 
and  so  applied  by  means  of  rubber  ligatures  or  rings,  as  to  draw 
forward  irregular  teeth.  The  ends  of  the  bar  are  screwed  to  the 
bicuspid  or  molar  tooth  on  either  side,  and  the  rubber  ligatures  or 
rings  pass  over  the  dovetail-shaped  parts  and  the  irregular  teeth. 
25 


,FiG.  146. 


386 


DENTAL    SURGERY. 


Fig.  147. 


I] 


si 


Fig.  147  represents  portions  of  metallic  bars,  a 
and  h,  with  holes  and  slits  for  elastic  ligatures  or 
rings ;  c  e  f,  portions  of  bars  with  hooks  and 
prominences  for  ligatures ;  d,  plate,  with  holes  for 
ligatures  (Farrar). 

Where  the  irregularity  consists  in  one  or  more 
of  the  superior  front  teeth  shutting  within  the 
inferior  teeth,  various  appliances  have  been  re- 
commended, the  oldest,  perhaps,  being  the  grooved 
plate  of  Duval,  and  inclined  plane  of  Catalan, 
which  consisted  of  a  simple  circular  bar  or  plate 
of  gold,  passing  in  front  of  the  teeth,  from  the 
first  molar  on  one  side  to  the  first  molar  on  the  other,  to  which  the 
inclined  plane  was  soldered. 

In  the  application  of  this  principle  for  the  correction  of  irregularity, 
the  author  has  been  in  the  habit  of  constructing  the  apparatus  some- 
what diflTerently.     With  a  metallic  die  and  counter-dies,  he  has  a  plate 
Fig.  148.  Fig.  149. 


of  gold  struck  up  over  all  the  teeth,  when  practicable,  as  far  back  as 
the  first  or  second  molar,  completely  encasing  them  and  the  alveolar 
ridge.  An  encasement  of  this  sort  (Fig.  148)  possesses  greater  sta- 
bility than  can  be  obtained  for  an  appliance  like  the  one  invented  by 
Catalan.  The  inclined  plane  represented  by  Fig.  148  can  be  more 
conveniently  constructed  of  vulcanized  rubber,  which  possesses  advan- 
tages over  metal  for  such  an  appliance. 

If  considerable  time  is  required  for  the  wearing  of  such  an  appliance 
as  an  inclined  plane,  injury  may  result,  as  the  masticating  teeth  are 
prone  to  elongate,  and  the  proper  articulation  of  the  teeth  be  impaired ; 
again,  if  the  patient  refuses  to  press  the  deviating  teeth,  on  account  of 
their  sensitive  condition  while  moving  upon  the  inclined  plane,  the  re- 
sult desired  will  not  be  accomplished. 

In  Fig.  150  the  letters  A  and  B  show  a  combination  of  an  inclined 
plane  with  elastic  ligatures,  designed  by  Dr.  N.  W.  Kiugsley,  to  correct 
an  irregularity  of  both  upper  and  lower  incisors,  and  the  same  appa- 
ratus was  used  as  a  retaining  plate  when  the  change  was  completed. 


IRREGULARITY   OF   THE    TEETH. 
Fig.  150.  Fig.  151. 


387 


'yjirnw     j^''^'"^  jL, 


Two  things  are  necessary  in  the 
treatment  of  this  form  of  irregularity: 
first,  to  prevent  the  upper  and  lower 
teeth  from  coming  entirely  together, 
by  placing  between  them  some  hard 
substance,  so  that  the  overlapping  incisors  may  not  interfere  with  the 
necessary  outward  movement.  The  second  is,  the  application  of  some 
fixture  that  will  exert  a  constant  and  steady  pressure  upon  the  devi- 
ating teeth,  until  they  pass  those  of  the  lower  jaw. 

Fig.  15  J  represents  another  appliance  of  Dr.  Farrar  for  correcting 
a  form  of  irregularity  where  the  teeth  incline  to  the  inside  of  the  arch. 
The  bar  {d),  in  Fig.  151,  is  made  of  thick  plate,  about  one-eighth  of  an 
inch  wide,  and  is  secured  at  one  end  (c)  to  a  molar  or  bicuspid  (or  both)  by 
means  of  a  clamp-band  (a  c  or  g),  while  the  other  extremity  rests  upon  a 
lateral  incisor.  This  forms  a  bridge  of  the  bar,  which  is  pierced  midway 
by  an  oblong  hole  through  which  is  passed  a  flat  screw  (b  b),  made  by 
filing  two  sides,  which  prevents  its  turning,  one  end  of  which  is  soldered 
to  a  thin  plate  (or  it  may  be  hammered  thin)  at  the  free  extremity  of 
which  is  soldered  a  thin  band  (b  b),  which  fits  tightly  around  the  crown 
of  the  cuspid  to  be  moved.  To  prevent  the  band  from  slipping,  a  metallic 
pin-point  may  be  soldered  on  its  inside  to 
fit  into  a  little  hole  drilled  into  the  tooth 
(or  the  band  may  be  attached  to  the 
crown  by  the  oxy chloride  or  oxyphosphate 
of  zinc  preparations,  and  no  hole  drilled 
into  the  tooth).  A  nut  (A)  is  then  tight- 
ened, which  draws  the  cuspid  into  posi- 
tion, and  at  the  same  time  forces  the 
lateral  incisor  (which,  in  the  case  repre- 
sented by  the  cut,  is  projecting)  inward. 

Fig.  152  represents  another  appliance  designed  by  Dr.  Farrar  for 
drawing  irregular  front  teeth  outward,  which  needs  no  explanation. 


Fig.  152. 


388 


DENTAL  SURGERY. 


For  drawing  irregular  projecting  teeth,  such  as  canines,  into  position, 
the  following  appliance  of  Dr.  F.  H.  Lee,  which  was  designed  as  an 
improvement  on  a  somewhat  similar  appliance  designed  by  Dr.  Littig, 
answers  the  purpose  admirably  : — 

The  Pull-back  Jack-screw's  special  use  is  for  drawing  in  obstinate 
canines  which  have  erupted  outside  of  the  line  of  the  arch,  but  it  will 

Fig.  153. 


work  with  equal  satis- 
faction on  any  of  the 
other  teeth. 

The  post  or  nut  is  set 
in  position  and  held  by 
vulcanizing  into  a  rubber 
plate  fitting  the  mouth  as 
shown  in  the  cut  (Fig. 
153);  the  screw-bolt  is 
then  placed  through  the 
post,  and  a  wire  or  liga- 
ture (wire  preferred)  is 
passed  around  the  tooth,  the  ends  being  secured^ to  the  holes  in  the 
cross-head  or  swivel-block.  The  wire  is  then  tightened  from  time  to 
time  as  the  tooth  is  brought  to  its  place.  To  prevent  the  plate  from 
being  moved  out  of  position  by  the  strain  upon  it,  it  should  be 
fastened  to  the  teeth  of  the  arch. 

Fig.   154. 


Fig.  155. 


Figs.  154,  155  and  156,  represent  a  form  of  irregularity  consisting 
of  the  misplacement  of  the  superior  canines  and  lateral  incisors,  and 
the  appliance  designed  by  Dr.  Jos.  Kichardson  for  correcting  it,  the 
principle  of  which  was  suggested  a  number  of  years  ago  by  Dr. 
Redman. 


IRREGULARITY  OF  THE  TEETH. 


389 


In  addition  to  the  mal place-  Ftg.  156. 

ment  of  the  lateral  incisors  and 
canines,  there  was  some  lateral 
contraction  of  the  arch.  After 
the  extraction  of  the  first  bi- 
cuspids a  narrow  band  of  vul- 
canized rubber  (Fig.  155), 
was  constructed,  embracing 
the  six  anterior  teeth.  Pressure  was  made  upon  the  misplaced  teeth 
by  means  of  wooden  pegs  inserted  in  holes  drilled  through  the  band, 
at  such  points  as  were  indicated  by  the  direction  in  which  it  was 
desired  the  teeth  should  take.  The  pegs  rested  against  the  posterior 
mesial  angles  of  the  lateral  incisors  in  such  a  way  as  to  force  them  out- 
ward and  backward,  while  those  inserted  into  the  opposite  or  labial 
portion  of  the  band  carried  the  canines  backward  and  inward.  These 
pegs  projected  but  slightly  at  first,  and  were  lengthened  from  time  to 
time,  as  the  teeth  moved. 


Fig.  157. 


Fig.  158. 


Dr.  Richardson  also  designed  the  following  appliance,  represented 
by  Fig.  157,  for  shortening  teeth  elongated  during  the  treatment  for 
irregularity 

It  consists  of  a  plate  affording  fixed  points  of  resistance  and  having 
clasps  attached  and  pinned  to  the  centrals  with  wooden  pegs  resting 
against  their  anterior,  and  the  plate  against  their  posterior  surfaces,  as 
represented  in  Fig.  157.  To  this  plate  firm  elastic  cords  were  attached 
stretching  across  the  openings  for  the  elongated  teeth.  When  this 
plate  was  pressed  firmly  to  its  place  upon  the  teeth  and  held  securely 
by  the  means  already  referred  to,  the  contractile  force  of  the  cords 
produced  the  necessary  shortening  of  the  elongated  teeth.  Fig.  156 
represents  the  elongated  laterals  as  shown  in  Fig.  158  in  their  proper 
positions. 

A  system  of  regulating  teeth  designed  by  Dr.  Jno.  J.  R.  Patrick,  is 


390 


DENTAL   SURGEEY. 


Fig.  159. 


simple  and  also  effectual,  and  differs  from  any  heretofore  referred  to. 
No  cast  of  the  mouth  is  required,  and  the  appliances  can  be  readily 
cleansed,  and  may  be  used  for  an  indefinite  number  of  times.  The 
power  employed  is  the  elasticity  of  a  bow-spring  (see  Fig.  159),  which 

consists  of  a  half-round 
gold  wire  and  platinum 
bar  (A  A),  curved  to 
correspond  with  the 
shape  of  the  arch,  having 
upon  it  a  number  of 
sliding  rings,  by  means 
of  which  anchorage  is 
secured  and  attachment 
made  to  the  teeth  to  be 
moved.  The  bar  is  bent 
with  its  flat  surface  in- 
ward, and  is  of  sufficient  length  to  allow  its  ends  to  rest  gently  on  the 
external  lateral  surfaces  of  the  first  and  second  molars,  as  desired.  The 
slides  are  fitted  accurately,  so  as  to  move  steadily.  Two  of  these,  which 
are  made  longer  for  the  purpose,  are  used  to  secure  anchorage,  by  sol- 
dering to  their  inner  surfaces  thin  gold  bands  (B  B),  previously  fitted 
to  the  teeth  selected.  The  bar  is  held  in  position  by  set-screws  (C  C), 
passing  through  them.  Small  buttons  are  soldered  to  their  external 
surfaces,  through  which  the  screws  pass,  to  give  them  greater  purchase. 
To  the  smaller  slides  the  different  appliances  for  moving  teeth  are 
attached,  as  wedges,  hooks,  T-bars,  loops,  and  bands  (D  E  F  G  H  I), 
of  various  sizes  and  shapes,  as  required.  The  apparatus  acts  as  a 
lever,  of  which  the  power  is  the  elasticity  of  the  bow-spring,  the  ful- 
crums  the  points  used  for  anchorage,  and  the  resistance  the  tooth  or 
teeth  to  be  moved.  If  these  are  outside  the  arch,  the  bow-spring  is 
adjusted  so  that  its  flat  surface  touches  all  of  the  projecting  teeth,  and 
is  firmly  set  with  the  set-screws.  The  wedges  are  then  forced  together 
between  the  teeth  to  be  moved  and  the  bar ;  should  the  wedges  cease 
to  act  before  the  teeth  are  properly  placed,  the  set-screws  are  loosened, 
the  wedges  separated,  and  the  bar  taken  up  until  its  inner  surface  is 
again  pressed  against  the  projecting  teeth,  when  it  is  again  set  firmly, 
and  the  wedges  are  again  brought  into  play.  To  move  teeth  outward, 
the  elasticity  of  the  bow-spring  is  made  to  draw  upon  them  by  means 
of  the  proper  appliance.  Rubber  bands  or  ligatures  may  be  made 
useful  auxiliaries.  This  appliance  can  be  used  on  either  jaw.  Should 
the  bar  at  any  time  exhibit  a  tendency  to  slip  toward  the  gum,  it  can 
be  held  in  place  by  snapping  one  of  the  slides  provided  with  a  hook 
over  the  cutting  edge  of  a  tooth. 


IRREGULARITY   OF   THE   TEETH. 


391 


Fig. 


As  comparatively  few  cases  of  irregularity  occur  which  in  their 
treatment  do  not  require  expansion  of  the  arch,  a  number  of  appliances 
have  been  designed  to  accomplish  such  an  object ;  such  as  a  hinged 
metallic  plate,  the  jack-screws,  either  by  direct  force  or  acting  on  split 
plates. 

One  of  the  most  satisfactory  appliances,  however,  for  expanding  the 
arch  is  the  invention  of  Dr.  Coffin,  of  London,  Eng.,  and  is  represented 
by  Figs.  160,  161.  It  consists  of  a  thin  vulcanite  plate  capping  some 
or  all  of  the  bicuspids 
and  molars,  and  fitting 
the  palatal  or  lingual 
surfaces  of  the  anterior 
teeth,  but  divided  along 
the  median  line  into  two 
distinct  halves,  connect- 
ed, however,  by  a  steel- 
wire  spring,  so  arranged 
that,  while  guiding  and 
limiting  the  relative  mo- 
tion of  the  two  halves  of 
the  plate,  its  tension  ex- 
erted between  them  may 
be  perfectly  varied  in  di- 
rection and  magnitude. 
The  impression  of  the 
mouth  should  be  obtained 
with  gutta-percha,  as  it  is 
elastic,  and  by  its  slight 

contraction  in  cooling,  yigg.  leo  and  1()1  are  typical  appliances  for  the  upper  and 

affords      a     ti^htlv-fittinff  lower  jaws.    The  wire  in  Fig.  160  shows  the  form  best  adapted 

,                U'    1,      I,                      •  for  expanding  the  anterior  portion  of  the  arch ;  that  in  Fig.  161 

plate,  which,    however,  is  (.{jg  form  adapted  to  enlarging  the  posterior  portion.     The  addi- 

not  inserted  in  the  mouth  tlonal  wire  on  the  left  of  Fig.  160  was  used,  in  the  case  above 

m. ,    .      T    .  T     1  mentioned,  to  force  the  lateral  incisor  outward. 
it  IS  divided. 

The  steel  spring  is  made  of  piano-forte  wire,  and  is  of  the  form 

shown  in  Fig.  162.     To  construct  the  spring  two  pairs  of  pliers  are 

necessary,  and  a  pair  of  clasp-benders.     After  cutting   the   proper 

length  of  wire,  from  one  to  two  and  a  half 

inches  in  average  cases,  the  wire  being  of  a 

diameter  between  three-  and  four-hundred ths 

of  an  inch  (about  0.035  inch),  it  should  be 

bent  first  in  the  centre,  and  then  back  on 

each  side,  with  the  clasp -benders,  holding  it 

with  the  pliers,  and  thus  giving  the  spring 


Fig.  162. 


392 


DENTAL   SURGERY. 


(as  a  serviceable  form)  the  shape  of  a  three-  or  five-curved  serpentine 
figure,  like  a  rounded  capital  W.  It  should  also  be  bent  to  fit  as 
nearly  as  possible  the  palatal  surface  of  an  upper  model,  or  the  lingual 
surface  of  a  lower  model,  and  its  ends  should  be  flattened  and  rough- 
ened, without  being  softened  by  heat,  for  half  an  inch  from  the 
extremities.  The  plate  being  modeled  in  wax,  the  spring  is  placed  on 
the  surface,  with  its  ends  buried  within,  and  when  removed  by  the 
counterpart,  protected  from  the  rubber  by  tin  foil  before  packing.  In 
making  the  spring  the  flattened  ends  should  be  coated  with  tin  ;  some 
are  in  the  habit  of  coating  over  the  entire  spring,  but  this  is  not 
necessary,  as  the  wire  after  it  is  worn  becomes  discolored  with  a  polished 
appearance.  Some  recommend  the  insertion  of  a  small  piece  of  zinc 
in  contact  with  each  of  the  ends  of  the  wire,  to  prevent  oxidation.  Old 
piano-forte  wire  is  said  to  be  the  best  for  these  springs.  The  plate  after 
being  vulcanized,  is  finished  in  the  usual  manner,  and  is  then  divided 
with  a  fine  saw,  the  edges  and  corners  of  the  cleft  being  made  round 
and  smooth.  It  is  recommended  to  have  the  patient  wear  the  plate  in 
the  mouth  for  a  day  or  two,  to  first  eliminate  any  causes  of  irritation 
not  due  to  its  expansive  action,  before  the  tension  is  made  by  opening 
the  spring.  The  patient  can  be  instructed  to  increase  the  tension  from 
time  to  time,  by  slightly  pulling  apart  the  two  halves  of  the  plate  and 

replacing  it  in  the  mouth. 

Fig.  163  represents  appli- 
ances of  Dr.  Farrar's  to  move 
irregular  teeth — the  first  to 
draw  teeth  together,  and  the 
second  to  separate  irregular 
teeth  in  making  space  for 
another. 

Fig.  164  represents  an  ap- 
pliance, also,  of  Dr.  Farrar's, 
in  position,  for  drawing  a  cus- 
pid toward  a  second  bicuspid, 
after  a  first  bicuspid  has  been 
extracted. 

For  moving  a  projecting 
incisor  or  cuspid  backward,  a 
gold  spiral  spring  was  former- 
ly employed.  It  was  found 
to  be  more  eflScient  than  a 
ligature  of  silk,  inasmuch  as 
it  kept  up  a  constant  traction 
upon  the  deviating  tooth.  But 


Fig.  163. 


IRREGULARITY    OF    THE   TEETH. 


393 


it  is  objectionable,  on  account  of  the  annoyance  it  causes  the  patient. 
A  ligature  of  rubber  is  far  preferable,  and  this  material  is  now  very 
generally  employed  in  the  treatment  of  every  description  of  irregu- 
larity  in   which   simple  Yig  164 
appliances  are  required. 
The  difficulty  of  tying 
India-rubber  ligatures  is 
obviated  by  the  use  of 
several  sizes  of  delicate 
elastic   tubing    (French 
manufacture),    from 
Avhich   sections  may  be 
cut,  more  or  less  thick, 
according  to  the  required 
length  and  power  of  the 
ligature.    Each  strip  be- 
comes  thus   an    endless 
band,    which     may    be 
readily  passed  from  one 
tooth  to  another  or  to  a  hook  on  the  plate. 

Where  the  superior  central  incisors  project  beyond  the  inferior  so 
much  as  to  give  a  pointed  appearance  to  the  lip,  Dr.  Kingsley  recom- 
mends the  following  regu- 
lating appliance  (Fig.  165)  :  a  ^^^-  l^^- 
rubber  plate  fitting  the  roof 
of  the  mouth  is  constructed  on 
a  plaster  model,  taken  from  a 
plaster  impression,  in  the  same 
manner  as  any  other  vulcan- 
ized rubber  plate  would  be 
made.  This  plate,  which  is 
made  as  delicate  as  strength 
and  durability  will  permit,  is 
cut  away  opposite  the  irregu- 
lar incisors,  so  that  there  may 
be  room  for  these  to  be  pressed 
in.  The  pressure,  which  is 
brought   to   bear    in  such    a 

manner  as  not  only  to  move  these  incisors,  but  act  more  or  less  upon 
the  whole  arch,  is  made  by  means  of  a  very  simple  contrivance,  such 
as  a  piece  of  gold,  formed  in  the  shape  of  a  T,  about  a  quarter  of  an 
inch  in  length,  and  with  a  staple  or  ring  at  the  bottom  of  the  upright 
portion  of  the  T,  through  which  a  ligature  may  be  passed.     This  liga- 


394 


DENTAL  SURGERY. 


Fig.  166. 


ture  is  a  rubber  ring,  cut  from  a  piece  of  small  rubber  tubing,  and  is 
passed  through  the  eyelet  in  the  T  and  then  attached  to  the  plate, 
reaching  directly  to  the  second  molars  on  either  side. 

The  plate  being  introduced  into  the  mouth,  the  T  is  brought  forward 
and  passed  between  the  central  incisors,  so  that  the  cross-bar  of  the  T 

is  brought  to  bear  upon  their 
labial  surfaces.     If  the  inci- 
sors are  in  close  contact,  space 
is  made  for  the  gold  bar  form- 
ing the  part  of  the  T  which 
projects  into  the  mouth,  by 
wedging.     The  effect  of  this 
appliance  will  be  to  draw  the 
central  incisors  inward,  and 
at  the  same  time  to  force  the 
side  teeth  outward.     To  pre- 
vent the  incisors  from  return- 
ing  to  their   abnormal 
position,  delicate  rubber 
rings  may  be  used,  being 
slipped  over  the  incisors 
and  attached  to  a  close- 
fitting    retaining    plate 
of  rubber  covering  the 
roof  of  the  mouth. 

Figs.  166  and  167 
will  represent  a  case  of 
irregularity  before  and 
after  treatment,  in  the 
treatment  of  which  the 
appliance  above  de- 
scribed is  applicable. 

Fig.  168  represents  a 
similar  appliance  for 
correcting  a  form  of 
irregularity  consisting 
of  the  projection  of  the 
superior  front  teeth, 
where  the  force  is  ap- 
plied to  all  of  the  pro- 
jecting teeth  at  once. 

Fig.  169  represents  a 
vulcanite  plate  with  an 


Fig.  168. 


IRREGULARITY   OF   THE   TEETH. 


395 


alloyed  o-old  and  platiuum  band  attached  by  means  of  screws,  suitable 
for  moving  back  projecting  front  teeth,  after  the  necessary  space  is  ob- 
tained by  extraction  of  a  bicuspid  on  each  side.  This  appliance  is  very 
effectual,   and    can    be 

regulated  by  the  patient  ^^^-  '^^^■ 

using  a  common  watch- 
key,  or  one  made  for  the 
purpose,  in  order  to  in- 
crease the  pressure  of 
the  band  upon  the  pro- 
jecting teeth.  Small 
hooks  attached  to  the 
front  portion  of  the 
band,  and  passing  over 
the  cutting  edges  of  the 
incisors,  prevent  the 
band  from  slipping  up 
to  the  gum. 

Fig.  170  represents  a 
form  of  special  loop  for  drawing  back  the  canines,  and  which  is  attached 
to  the  same  plate,  the  band  being  removed  until  after  these  teeth  are 
moved. 

A  special  plate  may  be  constructed  for  the  moving  of  the  canines, 
or  but  one  plate  be  employed,  made  of  the  form  represented  by  Fig. 
169,  and  which  can  be  afterwards  modified,  as  in  Fig.  171. 

Fig.  171. 


Fig.  170. 


Figs.  172  and  1 73  represent  an  ingenious  appliance  of  Dr.  Farrar  for 
laterally  moving  the  apices  of  the  roots  as  well  as  the  crowns  of  teeth.  It 
consists  of  gold  clamp-bands  operated  with  a  screw  ;  fulcrums  are  placed 
between  the  teeth,  to  prevent  the  crowns  from  moving  faster  than  the 


396 


DENTAL  SURGERY. 


entire  roots,  these  fulcrums  being  replaced  by  smaller  ones  astheteetb, 
under  the  pressure  of  the  clamp-band,  approach  each  other. 


Fig.  173. 


Fig.  172. 


.:5--' 


Retaining  plates  are  generally  required  after  the  operation  of  moving 
teeth  from  irregular  to  regular  positions  is  completed.  For  the  great- 
est difficulty  in  correcting  irregularity  of  the  teeth  is  often  caused  by 
the  tendency  of  such  teeth  to  return  to  their  old  positions.  It  is  neces- 
sary, therefore  that  retaining  plates  should  be  worn  until  the  corrected 
teeth  become  firmly  fixed ;  and  no  definite  time,  although  the  average 
time  may  be  stated  as  that  of  one  year,  can  be  given  for  the  comple- 
tion of  such  a  process.  Before  permanently  removing  a  retaining 
plate  its  use  may  be  dispensed  with  for  a  short  time,  an  examination 

being  made  daily,  to  deter- 
FiG.  174.  mine  if   there   is   any    ten- 

dency of  the  corrected  teeth 
to  return  to  their  irregular 
positions. 

A  simple  form  of  retaining 
plate,  to  be  worn  after  the 
correction  of  an  irregularity 
caused  by  the  projection  of 
the  superior  front  teeth,  is 
represented  by  Fig.  174, 
which  is  a  simple  vulcanite 
plate  with  a  small  gold  wire 
attached  to  it,  and  passing  to 
the  outside  of  the  front  teeth, 
through  a  small  opening  be- 
tween the  canine  and  bicuspid  teeth  on  each  side.  After  the  cor- 
rection of  a  contracted  arch,  a  simple  vulcanite  plate,  such  as  is 
represented  by  Fig.  175,  will  answer  as  a  retaining  plate.  A  plate 
of  this  kind  should  be  adapted  to  the  palatal  surfaces  of  all  the 
superior  teeth. 


IRREGULARITY    OF    THE    TEETH. 
Fig.  175. 


397 


Fio.  176. 


■ 


Fig.  177. 


Fig.  176  represents  an  ingenious  application  of  the  rubber  dam 
for  the_  retention  of  replanted  teeth,  and  which  may  also  be  utilized 
for  the  retention  of  one 
or  more' irregular  teeth 
after  treatment,  which  is 
the  suggestion  of  Dr. 
Herbst.  The  idea  is  so 
plainly  shown  by  the 
illustrations  that  further 
description  is  unneces- 
sary. 

Wedges  of  elastic  rub- 
ber are  often  useful  in 
cases  where  the  lower 
teeth  shut  outside  the 
upper  ones.  They  should 
be  used  of  such  a  thick- 
ness as  will  exert  a 
gentle  pressure  only. 

Fig.  177  represents  a  case  of  this  kind,  with  the  wedges  in  position. 

The  jack-screw  is  also  a  valuable  appliance  for  regulating  teeth. 


Fig.  178. 


Fig.  179 


Fig.  180. 


398 


DENTAL  SURGERY. 


Fig.  181. 


Its  use  was  first  suggested  by  Dr.  Wm.  H.  Dwinelle,  and  it  has  been 
applied  alone,  or  in  connection  with  a  split-vulcanite  plate.  Figs.  178 
and  179  represent  different  styles  of  jack-screws,  the  old  and  new,  and 
are  operated  by  holes  in  the  middle  bar ;  other  holes  render  them 
capable  of  being  secured  to  a  tooth,  thus  avoiding  the  danger  of  being 
swallowed  if  accidentally  detached.  In  some  cases,  one  end  of  the  first 
style  of  screw  has  been  permanently  imbedded  in  the  rubber  plate. 

Dr.  M.  H.  Cryer  has  designed  an  appliance  by  the  use  of  which  no 
injury  results  to  the  teeth  while  the  jack-screws  are  in  operation.  It 
consists  of  thin  platinum  bands  or  clasps  fitted  to  the  teeth,  the  ends 
either  soldered  or  held  together  by  a  small  screw.  The  clasp  which 
encircles  the  tooth  to  be  forced  outward  contains  a  small  hole  for  the 

reception  of  the 
point  of  the  jack- 
screw,  and  upon 
the  other  clasp, 
which  may  encircle 
several  teeth  used 
as  a  fulcrum,  small 
lugs  are  soldered, 
between  which  the 
other  end  of  the 
jack-screw,  which 
is  of  the  form  of  a 
crotch,  fits  tightly, 
and  is  thus  preven- 
ted from  slipping. 

Fig.  180  repre- 
sents a  vulcanite 
split-plate  with  a 
jack-screw  in  posi- 
tion. 

Fig.  181  repre- 
sents a  screw  which 
is  a  combination  of 
the  two  forms  al- 
ready alluded  to, 
having  upon  its 
end  a  revolving 
crutch.  Levers  are 
also  used  with  ad- 
vantage on  the 
outside  of  the  arch, 


IRREGULARITY    OF    THE   TEETH. 


399 


Fig. 184. 


to  press  with  a  geutle  force  a  deviating  tooth,  and  thus  move  it  into  a 
proper  position. 

Fig,  182  represents  a  plate  of  vulcanized  rubber  with  levers  or 
springs  attached. 

Shortening  the  teeth  has  already  been  referred  to  in  several  of  the 
cases  presented,  and  it 
remains  only  to  allude  to 
an  apparatus  designed  by 
Dr.  Kingsley  for  such  an 
object.  It  consists  of  a 
frame  of  gold  adapted  to 
the  cutting  edges  of  the 
incisors  and  lapping  on  to 
the  canines,  to  which  is 
added  a  stud  or  post  about 
half  an  inch  in  length, 
soldered  to  it  opposite  the 
canines,  and  coming  out  of 
each  corner  of  the  mouth. 
This  apparatus  is  shown 
by  Fig.  183.  The  arms 
extend  upward,  passing 
outside  the  cheeks,  and 
consist  of  metal  connected 
by  elastic  ligatures  to  a 
skull  cap.  '  Fig.  184  rep- 
resents the  entire  appa- 
ratus in  action. 

For  lengthening  a  short 
tooth.  Dr.  J.  D.  White 
suggests  the  simple  method 
of  tying  a  thread  ligature 
tightly  around  the  neck  of 
the  tooth,  under  the  free 
margin  of  the  gum,  and  if 
much  irritation  and  pain 
result,  to  remove  the  liga- 
ture, and,  keeping  the  tooth 
at  rest,  apply  a  little 
pounded  ice  in  a  bag  to  the  gum.  After  a  week's  rest,  the  same  treat- 
ment is  to  be  pursued  every  alternate  week,  until  the  end  is  accom- 
plished. But  great  care  is  necessary  to  keep  the  irritation  within 
proper  bounds,  this  treatment  being  applicable  only  to  growing  teeth, 
although  occasionally  to  matured  teeth  also. 


400 


DENTAL  SURGERY. 


The  following  is  an  appliance  designed  by  Dr.  Farrar  to  bring  into 
its  proper  place  in  the  arch  an  impacted  canine,  represented  by  Fig. 
185,  which  will  also  prove  effectual  for  elongating  a  tooth.  It  consists 
of  a  narrow  gold  plate  (see  Fig.  186j,  swaged  to  fit  the  palatal 
margins  of  the  gum  and  surfaces  of  the  lateral  incisors  and  bicuspids, 
with  thin  cross  bars,  or  a  clasp  around  the  first  bicuspid  connecting 
this  plate  with  a  smaller  one  adapted  to  the  labial  margin  of  the  gum. 
To  the  small  plate  or  pad,  as  it  is  termed,  a  smooth  nut  is  soldered, 
through  which  passes  a  screw,  its  lower  end  bent  so  as  to  enter  a 
small  hole  drilled  into  the  crown  of  the  short  tooth,  which  by  means 
of  a  thread-nut  is  forced  downward. 

The  elongated  tooth  is  retained  in  its  new  position  by  the  delicate 
apparatus  represented  by  Figs.  187  and  188. 


Fig. 186. 


Fig.  187. 


Fig.  188. 


The  action  of  an  elastic  sj)ring,  the  free  end  of  which  acts  upon  the 
short  tooth  while  the  other  is  imbedded  firmly  in  a  rubber  plate,  will 
often  answer  the  purpose  of  elongating  a  tooth. 

In  conclusion,  to  sum  up  briefly,  do  not  interfere  Avhere  by  simple 
extraction  the  case  will  correct  itself;  when  teeth  must  be  moved,  do  it 
decidedly,  to  avoid  tedious  delay ;  but  take  care  not  to  be  so  rapid  as 
to  excite  inflammation  ;  do  not  move  teeth  with  deformed  or  defective 
roots ;  do  not  sacrifice  sound  and  regular  bicuspids  to  bring  into  the 
arch  teeth  which  will  require  to  be  moved  through  a  great  space,  for 
this  movement  materially  impairs  their  durability  ;  lastly,  do  not 
attempt  to  bring  teeth  to  a  position  Avhere  you  cannot  keep  them  until 
firm  ossific  deposit  makes  them  permanent  in  their  new  positions. 


IREEGULARITY   OF    THE   TEETH. 


401 


Dr.  Kingsley  is  of  the  opinion  that  a  correct  judgment  can  rarely  be 
formed  of  the  proper  treatment  necessary  in  any  case  of  irregularity 
which  necessitates  a  change  in  the  expression  of  the  mouth,  from 
plaster  models  alone,  as  an  opinion  formed  by  the  most  experienced 
observer  on  a  cursory  examination,  may  be  changed  upon  a  more 
careful  study  of  the  features,  the  family  type,  and  the  model  of  the 
teeth.  The  same  writer  remarks :  "  It  is  not  always  advisable  to 
attempt  to  change  the  expression  of  a  mouth  where  the  condition  is  an 
inherited  peculiarity,  a  part  of  the  family  type,  and  where  the  change 
would  involve  a  very  prolonged  effort,  possible  breaking  up  of  a  good 
articulation  of  masticating  organs,  and  with  the  knowledge  that  nature 
will  be  constantly  making  an  effort  to  return  to  the  hereditary  type." 

Deformity  from  Excessive  Development  of  the  Teeth  and  Alveolar  Ridge 
of  Lower  Jaiv. — When  the  teeth  of  the  lower  jaw  form  a  larger  arch 
than  those  of  the  upper,  the  incisors  and  cuspids  of  the  former  shut  in 
front  of  those  of  the  latter,  causing  the  chin  to  project,  and  otherwise 
impairing  the  symmetry  of  the  face.     Figs.  189  and  190  present  a 


Fig.  190. 


Fig.  189 


front  and  a  side  view  of  this  deformity.  It  may  result  from  a  want  of 
correspondence  in  the  development  of  the  teeth  and  alveoli  of  the  two 
maxilla,  the  upper  jaw  being  defective  in  size,  while  the  lower  jaw  is 
natural ;  or  the  former  being  natural,  the  latter  may  be  in  excess.  It 
may  also  arise  from  a  simple  eversion  of  the  lower  teeth  or  inversion 
of  the  upper. 

Treatment. — The  remedial  indications  of  the  deformity  in  question 
consist  in  diminishing  the  size  of  the  dental  arch,  which  is  always  a 
tedious  and  difficult  operation,  requiring  great  patience  and  persever- 
ance on  the  part  of  the  patient,  and  much  mechanical  ingenuity  and 
skill  on  the  part  of  the  dentist.  The  appliances  to  be  employed  have 
of  necessity,  to  be  more  or  less  complicated,  requiring  the  most  perfect 
26 


402 


DENTAL   SURGERY. 


accuracy  of  adaptation  and  neatness  of  execution  ;  they  must  also  be 
worn  for  a  long  time,  and,  as  a  natural  consequence,  are  a  source  of 
considerable  annoyance.  The  first  thing  to  be  done  is  to  extract  the 
first  inferior  bicuspids.  Suflacient  room  will  thus  be  obtained  for  the 
contraction  which  it  will  be  necessary  to  effect  in  the  dental  arch  for 
the  accomplishment  of  the  object.  An  accurate  impression  of  the 
teeth  and  alveolar  ridge  should  be  taken  with  wax,  softened  in  warm 
water,  and  from  this  impression  a  plaster  model  is  procured,  and 
afterward  a  metallic  die  and  counter-die,  in  the  manner  to  be  described 
in  a  subsequent  chapter. 

This  done,  a  gold  plate  of  the  ordinary  thickness  should  be  swaged 
to  fit  the  first  and  second  molars  (if  the  second  has  made  its  appear- 
ance, and  if  not,  the  second  bicuspid  and  first  molar  on  each  side), 
so  as  completely  to  encase  these  teeth.     If  these  caps  are  not  thick 
•  enough  to  prevent  the  front  teeth  from  coming  together,  a  piece  of 


Fig.  191. 


Fig.  192. 


gold  plate  may  be  soldered  on  that  part  of  each  which  covers  the 
grinding  surfaces  of  the  teeth.  Having  proceeded  thus  far,  a  small 
gold  knob  is  soldered  to  the  inner  and  outer  front  corners  of  both 
caps,  and  to  each  of  these  a  ligature  of  silk  or  rubber  is  attached. 
These  ligatures  are  to  be  brought  forward  and  tied  tightly  around  the 
cuspids.  When  thus  adjusted,  the  lower  arch  will  present  the  appear- 
ance exhibited  in  Fig.  191.  By  this  means  the  cuspids  may,  in  fifteen 
or  twenty  days,  be  taken  back  to  the  bicuspids.  If  in  their  progress 
they  are  not  carried  toward  the  inner  part  of  the  alveolar  ridge,  the 
outer  ligatures  may  be  left  off"  after  a  few  days,  and  the  inner  ones 
alone  employed  to  complete  the  remainder  of  the  operation. 

After  the  positions  of  the  cuspids  have  been  thus  changed,  a  circular 
bar  of  gold  should  be  made,  extending  from  one  cap  to  the  other,  so 
as  to  pass  about  a  quarter  of  an  inch  behind  the  incisors,  and  be 
soldered  to  the  inner  side  of  each  cap.  A  hole  is  to  be  made  through 
this  band,  behind  each  of  the  incisors,  through  which  a  ligature  of  silk 


IRREGULARITY    OF   THE   TEETH. 


403 


may  be  passed  and  brought  forward  and  tied  tightly  in  front  of  each 
tooth.  These  ligatures  should  be  renewed  every  day  until  the  teeth 
are  carried  far  enough  back  to  strike  on  the  inside  of  the  corresponding 
teeth  in  the  upper  jaw. 

Fig.  192  represents  the  appearance  which  the  lower  jaw  presents 
with  the  last-named  apparatus  upon  it,  and  will  better  convey  an  idea 
of  its  construction,  the  manner  of  its  application,  and  its  mode  of 
action,  than  any  description  which  can  be  given. 

An  appliance  of  this  sort  may  be  made  to  act  with  great  efficiency 
in  remedying  the  deformity  in  question ;  but,  in  its  application,  it  is 
necessary  that  the  caps  •be  fitted  with  the  greatest  accuracy  to  the 
teeth,  and  they  should  be  removed  every  day  and  thoroughly  cleansed, 
as  well  as  the  teeth  they  cover.  If  this  precaution  is  neglected,  the 
secretions  of  the  mouth,  which  collect  between  the  gold  caps  and  teeth, 
will  soon  become  acid,  and  corrode  the  latter. 

The  remarks  made  in  the  previous  chapter  upon  the  use  of  the 
vulcanite  are  applicable  here.  Such  a  plate,  for  this  class  of  cases,  is 
readily  made,  and  inflicts  no  injury  upon  teeth  or  gums.  Elastic,  in- 
stead of  silk,  ligatures  might  be  used,  and  the  retraction  of  the  incisors 
carried  on  simultaneously  with  that  of  the  cuspids.  The  use  of  vul- 
canized rubber  instead  of  gold  is  of  great  value  in  correcting 
irregularities  of  this  nature,  the  form  of  the  appliances  being  the 
same. 

The  employment  of  elastic  rubber  ligatures  in  connection  with 
vulcanite  plates  is  generally  found  to  be  effectual  in  correcting  the 
irregularity  of  the  inferior  front  teeth.  The  following  appliances,  from 
designs  of  Dr.  Kingsley,  will  be  found  serviceable : — 

Fig.  193  represents   an 
appliance  for  correcting  an  '^^^'  ^^^' 

irregularity  where  the  in- 
ferior canine  teeth  stand 
outside  the  arch,  which  is 
somewhat  narrow  ;  the  first 
permanent  molars  being 
first  extracted.  Hooks  of 
gold  wire  are  inserted  in 
the  plate  as  points  of  at- 
tachment for  the  elastic 
bands,  which  are  drawn 
forward  and  attached  to 
the  canines  by  silk  or  linen 
threads.  By  such  means 
the  canines  were  drawn  into  position  and  the  arch  widened. 


404 


DENTAL  SUEGEEY. 


Fig.  194  represents  other  forms  of  attachment  for  elastic  bands  and 
ligatures. 

Fig.  195  shows  an  appliance  for  correcting  the  irregular  arrange- 
ment of  the  four  inferior  incisors.  Gold  wire  hooks  (A  A),  pass  over 
the  arch  between  the  canines  and  adjoining  teeth,  in  order  to  give  an 
independent  attachment  for  the  elastic  ligatures  outside  as  well  as 
within  the  arch,  and  movements  in  almost  any  direction  can  be 
obtained.  For  cleansing  purposes  such  appliances  can  be  removed 
and  replaced  by  the  patient. 

Protrusion  of  the  Lower  Jaw. — This  deformity,  although  produced  by 
a  different  cause  from  the  one  last  described,  is  similar  to  it,  and  gives 
to  the  lower  part  of  the  face  an  unnatural  and  sometimes  disagreeable 
appearance.  It  also  interferes  with  mastication,  and  often  with  pre- 
hension and  distinct  utterance.  It  wholly  changes  the  relationship 
which  the  teeth  should  sustain  to  each  other  when  the  mouth  is  closed. 


Fig.  194. 


Fig.  195. 


The  cusps  or  protuberances  of  the  bicusjDids  and  molars  of  one  jaw, 
instead  of  fitting  into  the  depressions  of  the  corresponding  teeth  of  the 
other,  often  strike  their  most  prominent  points;  at  other  times,  the 
outer  protuberances  of  the  lower  molars  and  bicuspids,  instead  of  fitting 
into  the  depressions  of  the  same  class  of  teeth  in  the  upper  jaw,  shut  on 
the  outside  of  these  teeth.  The  trituration  of  aliments  is  consequently 
rendered  more  or  less  imperfect. 

This  protrusion  of  the  lower  jaw  is  supposed  by  some  to  be  the  result 
of  a  "  natural  partial  luxation."  In  fact,  its  causes  are  by  no  means 
clearly  understood.  It  is  often  hereditary,  and  would  seem  to  be 
caused  by  that  mysterious  agency  which  impi'esses  peculiarities  of  growth 
and  shape  not  only  upon  the  lower  maxilla,  but  upon  every  bone  in  the 
body.  The  agency  is  so  constant  and  overruling,  that  we  must  be 
prepared  to  find  the  jaw  returning  to  its  position  after  the  discontinu- 
ance of  treatment ;  unless,  by  the  interlocking  of  the  cusps  of  the  upper 


IREEGULARITY   OF    THE   TEETH. 


405 


Fig.  196. 


teeth  and  the  overlapping  of  the  upper  incisors,  we  can  restrain  the 
tendency.  It  is  of  more  frequent  occurrence  than  the  one  which  results 
from  excessive  development  of  the  teeth  and  alveolar  ridge,  and  requires, 
as  before  stated,  an  entirely  diiferent  plan  of  treatment.  It  rarely 
occurs  previously  to  second  dentition. 

Treatment. — The  plan  of  treatment  formerly  adopted  consisted  in 
fastening  on  each  side  a  cap  of  vulcanite  on  one  of  the  lower  molars, 
thick  enough  to  keep  the  front  teeth  about  a  quarter  of  an  inch  apart 
when  the  jaws  were  closed.  Fox's  bandage  was  then  applied.  This 
was  buckled  as  tightly  as  the  patient 
could  bear  with  convenience,  pressing 
the  chin  upward  and  backward.  A 
piece  of  tough  wood,  slightly  hollowed 
so  as  to  fit  the  arch  of  the  lower 
teeth,  made  narrow  at  the  upper  end, 
was  introduced  between  the  teeth  sev- 
eral times  a  day,  the  concave  portion 
resting  upon  the  outside  of  the  lower 
and  against  the  inside  of  the  upper, 
employing  at  each  time  as  much  pres- 
sure as  could  be  safely  applied.  By 
continuing  this  operation  from  day 
to  day,  for  several  weeks,  the  natural 
relationship  of  the  jaws  would,  in  most 
cases,  be  restored. 

The  description  of  bandage  here  alluded  to,  and  the  manner  of  its 
application,  is  represented  in  Fig.  196.  When  the  protrusion  of  the 
lower  jaw  is  accompanied  by  irregularity,  means  should  at  the  same 
time  be  employed  for  remedying  it.  The  earlier  the  treatment  is  insti- 
tuted, the  more  easily  will  the  deformity  be  overcome.  It  may,  how- 
ever, be  successfully  remedied  at  any  time  previously  to  the  twentieth 
year  of  age,  and  sometimes  at  a  much  later  period ;  but  after  this  time 
the  operation  becomes  more  difficult. 

An  appliance  designed  by  Dr.  G.  S.  Allan  (Fig,  197),  and  which  he 
employed  successfully,  consists  of  a  brass  plate  to  fit  the  chin,  having 
arms  with  hooked  ends  reaching  to  a  point  just  below  the  point  of  the 
chin.  The  arms  are  arranged  in  such  a  way  that  the  distance  be- 
tween them  can  be  altered  at  will  by  simply  pressing  them  apart  or 
together.  The  upper  part  consists  of  a  simple  network  going  over  the 
head,  and  having  two  hooks  on  each  side,  one  hook  being  above  and 
the  other  below  the  ear.  The  network  and  the  chin -plate  are  connected 
by  four  elastic  rubber  ligatures,  exerting  pressure  in  such  a  manner  as 
to  force  the  lower  jaw  almost  directly  backward.      The  upper  elastics 


406 


DENTAL  SURGERY. 


are  used  simply  to  keep  the  mouth  closed  so 
not  pull  it  open  ;  the  upper  being  made  just 
muscles  of  the  mouth  need  not  be  strained  to 
the  operations  of  eating  and  talking. 

Fig.  197. 


/ 


!;^\ 


'Hi  I  '/I'/ii" 


rence ;  hence,  the  dentist  is  seldom  called 
nuity  and  skill  in  its  treatment. 


that  the  lower  elastics  will 
strong  enough  so  that  the 
keep  the  jaw  open  during 

In  cases  where  the 
lower  front  teeth  close 
over  the  upper,  and  thus 
cause  a  deformity  of 
the  face,  it  is  important 
to  discriminate  correctly 
between  those  which  re- 
sult from  malformation, 
and  a  protrusion  of  the 
jaw  occasioned  by  par- 
tial luxation,  as  the 
remedial  indications  in 
the  two  are  entirely  dif- 
ferent. Those  which 
would  prove  successful 
in  the  one  would  prove 
unsuccessful  in  the  other. 
But,  fortunately,  deform- 
ity arising  from  the  last 
mentioned  cause  is,  com- 
paratively, of  rare  occur- 
upon  to  exercise  his  inge- 


CHAPTER  II. 


TREATMENT   OF   DEXTAL   CARIES. 

rpHE  treatment  of  dental  caries  is  one  of  the  most  important  opera- 
J-  tions  in  dental  surgery,  because  of  the  usefulness  of  the  organs  to 
be  saved ;  the  universality  of  the  disease ;  also,  the  complex  and  diffi- 
cult nature  of  the  treatment  required.  The  caries  may  be  slight  and 
superficial ;  or  it  may  be  more  or  less  deep-seated ;  lastly,  it  may  pene- 
trate even  to  the  pulp  cavity.  The  difficulties  of  treatment  increase 
in  the  same  order,  and  in  this  order  they  will  be  taken  up.  Caries, 
wlien  superficial,  may  be  arrested  by  the  same  means  used  for  deeper 


TREATMENT   OF   DENTAL   CARIES.  407 

caries;  but  in  a  large  number  of  cases  it  will  require  for  its  removal 
only  the  use  of  files,  enamel  chisels,  or  disks.  These  instruments  are 
also  often  used  preparatory  to  the  operations  necessary  for  the  arrest  of 
deep-seated  caries ;  hence  their  use  demands  our  first  consideration. 

Treatment  of  Superficial  Caries. — There  is  no  operation  in 
dental  surgery  against  which  a  stronger  or  more  universal  prejudice 
prevails  than  that  of  filing  the  teeth ;  yet,  when  judiciously  and  skill- 
fully performed,  there  is  no  one  more  beneficial  or  effectual  in  arresting 
the  progress  of  caries.  Although  productive  of  much  good,  it  is,  in 
the  hands  of  unskillful  operators,  a  source  of  incalculable  injury. 

Dr.  John  Harris  says :  *  "  Filing  the  teeth  is  one  of  the  most  important 
and  valuable  resources  of  the  dental  art ;  it  is  one  that  has  stood  the  test 
of  experience,  and  is  of  such  acknowledged  utility,  as  to  constitute  of 
itself,  in  the  treatment  of  superficial  caries  on  the  lateral  surfaces  of 
the  teeth,  one  of  the  most  valuable  operations  that  can  be  perfoi'med 
on  these  organs.  And  even  after  caries  in  the  localities  just  men- 
tioned has  progressed  so  far  as  to  render  its  removal  by  this  means 
impracticable  or  improper,  the  use  of  the  file,  in  most  cases,  is  still 
necessary  in  order  to  the  successful  employment  of  other  remedial 
agents.  But  in  either  case  a  failure  to  accomplish  the  object  for 
which  it  is  used  would  only  be  equivalent  to  doing  nothing  at  all. 

"The  use  of  the  file,  then,  may  very  justly  be  considered  a  sine  qua 
non  for  the  removal  of  superficial  caries  from  the  sides  of  the  teeth 
which  come  in  contact  with  each  other,  as  can  be  attested  by  thousands 
of  living  \yitnesses ;  and  in  preparing  the  way,  in  deep-seated  caries, 
for  the  thorough  removal  of  the  disease,  and  filling  successfully  the 
cavity  thus  formed. 

"  The  fact  that  the  crowns  of  the  teeth  are  covered  with  enamel,  is 
alone  sufficient  evidence  of  its  importance  and  utility  in  shielding  and 
protecting  the  bony  structure  which  it  envelops  from  mechanical  and 
morbid  influences;  so  that  it  would  seem  that  its  removal  or  loss  would 
necessarily  expose  the  organs  to  certain  destruction.  But  we  have 
satisfactory  evidence  that  teeth,  after  having  sufiered  the  loss  of  large 
portions  of  the  enamel,  have  been  restored  to  health,  and  preserved  for 
many  years,  and  often  through  life. 

"The  rapidity  with  which  caries  progresses  after  the  exposure  of 
the  dentine  by  the  loss  of  the  enamel,  depends  upon  the  physical  pecu- 
liarities of  the  teeth,  and  upon  local  and  constitutional  influences; 
hence  the  difficulty,  and  oftentimes  impossibility,  of  obtaining  the  object 
for  which  dental  operations  are  instituted  while  such  influences  are 
sufiered  to  exist.     If  special  regard  is  not  had  to  the  curative  indica- 

*  These  remarks  are  applicable  to  all  instruments  employed  for  the  same  pur- 
pose as  the  file,  such  as  enamel  chisels,  corundum  and  diamond  disks,  etc.,  etc. 


408  DENTAL,   SURGEEY. 

tious,  most,  if  not  all  the  operations  upon  the  teeth  which  have  for 
their  object  their  ultimate  preservation,  are  sure,  to  a  greater  or  less 
extent,  to  augment  all  of  the  previously  existing  local  affections,  by 
increasing  the  irritability  of  the  parts,  and  by  rendering  them  more 
susceptible  of  being  acted  upon,  both  by  local  and  constitutional  causes. 

"  There  is  no  instrument  so  well  adapted  as  the  file  for  the  removal  of 
the  disease  when '  situated  in  these  parts  of  the  teeth,  especially  Avhen 
the  organs  are  in  close  proximity  with  each  other ;  or  for  the  removal 
of  rough  and  weakened  edges  of  the  enamel  in  deep-seated  caries,  and 
for  making  sufficient  space  or  room  for  the  removal  of  the  diseased 
parts  preparatory  to  plugging. 

"  It  may  be  laid  down  as  a  rule,  from  which  exceptions  should  never 
be  taken,  that  the  file  should  not  be  used  while  the  teeth  or  their  con- 
tiguous parts  are  suffering  general  or  local,  acute  or  chronic,  inflamma- 
tion. Therefore,  when  this  is  the  case,  the  treatment  of  the  general 
and  local  affections  should  precede  the  operation  of  filing.  Upon  the 
removal  of  all  the  acute  or  chronic  diseases  of  the  mouth  greatly  de- 
pends the  success  of  the  dentist  in  the  treatment  of  affections  of  the 
teeth  calling  for  the  employment  of  the  file.  As  much  importance, 
therefore,  is  to  be  attached  to  an  enlightened  and  discriminating  judg- 
ment as  to  tact  in  the  performance  of  the  operation. 

"In  fact,  the  removal  of  all  local  causes  of  irritation — such  as  dead 
roots  of  teeth,  teeth  occasioning  alveolar  abscesses,  or  such  as  exert  a 
morbid  influence  upon  the  surrounding  parts,  and  all  depositions  of 
salivary  calculus  or  other  foreign  matter — should  precede  all  other 
operations  upon  these  organs. 

"  The  length  of  time  necessary  for  the  restoration  of  the  parts  con- 
tiguous to  the  teeth  may  vary  from  a  few  days  or  weeks  to  as  many 
months,  depending  upon  the  nature  and  extent  of  the  disease,  the 
general  health  of  the  patient,  and  the  constitutional  as  well  as  local 
treatment  to  which  they  are  subjected. 

"  In  assuming  the  position  that  filing  the  teeth  does  not,  of  necessity, 
cause  them  to  decay,  it  is  by  no  means  to  be  inferred  that  the  opera- 
tion can,  in  all  cases,  and  under  all  circumstances,  be  performed  with 
advantage  or  even  impunity.  Its  effects,  like  those  of  most  other  opera- 
tions upon  the  teeth,  when  the  curative  indications  are  disregarded,  or 
not  properly  carried  out,  are  most  injurious.  The  employment  of  the 
file  at  an  improper  time  and  in  an  improper  manner  increases  the 
liability  of  teeth  to  decay  ;  it  augments  the  irritability  of  all  the  parts 
adjacent  to  them,  and  consequently  their  susceptibility  of  being  acted 
upon  by  local  and  constitutional  causes. 

"  Notwithstanding  the  utility  and  value  of  the  operation,  filing  the 
teeth  may  be  regarded  as  a  predisposing  cause  of  caries.     If  this  be 


TREATMENT   OP   DENTAL   CARIES.  409 

true,  it  may  be  asked,  why  file  at  all?  I  answer,  in  this  country, 
owing  to  the  prevalence  of  the  immediate  or  direct  cause  of  caries, 
the  operation  is  only  performed  as  remedial,  for  the  purpose  of  re- 
moving actual  disease  or  as  preparatory  to  plugging.  It  does  not,  of 
necessity,  follow  that  caries  of  the  teeth,  after  having  been  judiciously 
removed  or  treated,  although  the  organs  be  predisposed  to  the  disease, 
will  ever  again  occur.  The  general  system  often  escapes  the  develop- 
ment of  those  diseases  to  which  it  is  predisposed  through  life;  so  also  do 
the  teeth.  If  the  operation  be  properly  performed,  and  the  filed  surfaces 
kept  thoroughly  clean,  a  recurrence  of  the  disease,  notwithstanding 
the  increased  predisposition  thus  induced,  will  never  take  place.  The 
immediate  cause  of  dental  caries  being  the  contact  of  corrosive  agents 
with  the  teeth,  the  necessity  for  this  precaution  is  obvious.  The  bony 
structure  of  these  organs  is  more  easily  acted  upon  by  such  causes 
than  the  enamel;  for  this  reason,  when  it  becomes  necessary  to  expose 
it  with  a  file,  for  the  removal  of  disease,  it  should  be  done  in  such  a 
way  as  to  admit  of  its  being  kept  thoroughly  and  constantly  clean ; 
so  that,  if  it  afterward  becomes  carious,  it  will  be  owing  altogether  to 
inattention  of  the  patient.  In  view  of  this,  whenever  it  becomes  neces- 
sary to  file  the  teeth,  whether  for  the  complete  removal  of  caries,  or  as 
only  preparatory  to  plugging,  we  should  always  impress  upon  the  pa- 
tient the  importance  of  cleansing  the  surfaces  thus  operated  upon  at  least 
three  or  four  times  every  day.  The  future  preservation  of  the  organs 
will  depend  upon  the  constant  and  regular  observance  of  this  precau- 
tion, especially  when  they  are  of  a  soft  or  chalky  texture,  for  they  are 
then  far  more  easily  acted  upon  by  decomposing  agents  than  when  hard. 

"  The  cases  requiring  the  use  of  the  file  vary  so  much  that  it  would 
be  difficult  to  lay  down  precise  directions  with  regard  to  the  extent  to 
which  the  operation  should  be  carried.  This  must  be  determined  by 
the  judgment  of  the  operator.  The  design  of  the  operation  may  be 
defeated  either  by  filing  too  much  or  too  little.  Either  extreme  should 
be  avoided ;  but  it  is  my  opinion  that  by  far  the  greater  number  of 
unsuccessful  results  are  attributable  rather  to  the  too  moderate  than  to 
the  too  great  use  of  this  instrument,  especially  where  the  circumstances 
of  the  case  have  nothing  to  do  in  determining  the  result." 

In  filing  the  front  teeth  and  those  on  the  right  side  of  the  mouth, 
the  operator  should  stand  to  the  right  and  a  little  behind  the  patient, 
in  order  to  steady  the  head,  as  it  rests  against  the  back  of  the  operating 
chair,  with  his  left  arm  ;  while  with  the  fingers  of  the  left  hand  the  lips 
are  raised  and  the  teeth  properly  exposed  for  the  operation.  In  filing 
the  teeth  on  the  left  side  of  the  mouth,  it  may  be  necessary  for  the 
operator  to  stand  upon  the  left  side  of  his  patient.  The  file,  firmly 
grasped  between  the  thumb  and  middle  finger  of  the  right  hand,  with 


410  DENTAL   SURGERY. 

the  end  of  the  forefinger  resting  upon  its  outer  end,  should  be  moved 
backward  and  forward  in  a  direct  line,  as  any  deviation  from  this 
would  immediately  snap  the  instrument.  The  first  opening  between 
the  teeth,  when  the  approximal  edges  of  the  two  are  carious,  should  be 
made  with  a  flat  file,  about  one-fourth  of  a  line  in  thickness,  cut  on 
both  sides  and  both  edges ;  this  done,  a  file  cut  on  one  side  and  both 
edges  should  be  employed  for  the  completion  of  the  operation.  If  only 
one  tooth  is  decayed,  the  operation  may  be  commenced  and  completed 
with  a  safe-sided  file.  The  file,  during  the  operation,  should  be  fre- 
quently dipped  in  tepid  water,  to  prevent  it  becoming  heated  or  clogged 
while  in  use ;  especially  should  the  water  be  warm  or  tepid  where  the 

teeth  are  sensitive.    When 
YiG.  198.  the  files  become  so  much 

,  ^^ —      _  clogged  that  the  water  or 

V-  ^ -  "  a   brush  will   not  cleanse 

/  ..;^- :       -  them,    a     brass    or    steel 

^^^^^=— ^ — ^ -^  ' ..-  —  -       scratch-brush  may  be  used, 

gr=" — '-~-    '"' — mLM       '  1   w  Mmj     /  sulphuric    or    chlorhydric 

..^  _  ' *  ►  ^      acid,  and  then  washed  with 

V  '^"^^ — ''"• — — ' the  greatest  care,  to  remove 

every  trace  of  acid. 

Fig.  198  represents  various  forms  of  the  thin  separating  file. 

To  secure  the  success  of  the  operation,  it  is  sometimes  necessary  to 
cut  away  a  considerable  portion  of  the  tooth ;  but  in  doing  this,  the 
operator  should  be  careful  not  to  destroy  the  symmetry  of  the  labial 
surface.  The  aperture,  anteriorly,  should  only  be  wide  enough  to 
admit  of  a  free  oblique  or  diagonal  motion  of  a  safe-sided  file  of  about 
one-fourth  of  a  line  in  thickness,  or  a  correspondingly  thin  corundum 
disk.  In  this  way,  one-fourth  or  moi-e  of  a  tooth  may  be  removed 
without  materially  altering  its  external  appearance.  But  a  tooth 
should  not  be  filed  entirely  to  the  gum  ;  a  shoulder  should  be  left,  to 
prevent  its  approximation  to  the  adjoining  tooth.  Sometimes  the  decay 
is  of  such  size  and  so  situated,  that  it  may  be  removed  by  means  of 
enamel  chisels,  with  less  alteration  in  the  external  or  labial  surface  of 
the  tooth.  These  very  valuable  instruments  will  also  be  found  useful 
for  rapid  cutting  preparatory  to  the  slower  action  of  the  file.  A  rounded 
form  can  be  given,  by  them,  to  the  inner  angles  of  the  teeth,  for  which 
purpose  they  may  either  follow  or  take  the  place  of  the  file. 

Fig.  199  represents  a  set  of  enamel  chisels,  strait  and  curved,  by 
which  the  operation  of  removing  a  portion  of  the  crown  of  a  tooth  can 
be  performed  much  more  rapidly  than  by  the  file,  and  also  with  more 
comfort  to  the  patient. 


TREATMENT   OF   DENTAL   CARIES. 
Fig.  199. 


411 


Fig.  200  represents  a  set  of  Dr.  Louis  Jack's  Double-end  Enamel 
chisels. 

Fig.  200. 


Fig.  201  represents  Dr.  W.  W.  Evans'  set  of  Enamel  Chisels. 

When  operating  upon  the  front  teeth  with  the  enamel  chisel,  the  in- 
strument should  be  firmly  grasped  in  the  hand,  near  to  its  cutting  edge, 
and  the  edge  applied  to  the  surface  of  the  portion  to  be  removed,  while 
at  the  same  time  the  point  of  the  thumb  uses  as  a  fulcrum  the  cutting 
edge  of  the  tooth  or  the  one  adjoining. 

For  operating  upon  the  bicuspid  and  molar  teeth,  heavier  enamel 
chisels  are  required  than  in  the  case  of  the  front  teeth,  and  with  either 
straight  or  oblique  cutting  edges.     The  curved  form  of  chisel  is  useful 


412 


DENTAL   SURGERY. 


when  the  mouth  is  small,  and  it  is  difficult  to  reach  the  point  desired 
with  the  straight  form. 

When  the  decay  occupies  a  large  portion  of  the  approximal  surface, 
and  has  penetrated  into  the  tooth  to  a  considerable  depth,  destroying 
the  enamel  anteriorly,  and  causing  it  to  present  a  ragged  and  uneven 
edge,  it  will  be  necessary  to  form  a  wider  exterior  aperture  than  mere 
regard  for  appearance  would  dictate.  When  the  approximal  surfaces 
of  the  two  front  teeth  are  affected  with  caries,  about  an  equal  portion 
should,  if  circumstances  permit,  and  it  is  necessary  to  cut  away  tooth 
substance,  be  filed  or  cut  from  each  tooth.  In  the  case  of  delicate 
front  teeth,  or  teeth  slightly  loose  in  their  cavities,  it  will  be  well,  be- 
fore filing,  to  mould  a  small  piece  of  gutta  percha,  or  modeling  compo- 
sition, around  or  against  the  inner  surfaces  of  the  tooth  to  be  filed  and 
several  adjoining  ones.     It  gives  support  to  frail  teeth,  and  greatly  les- 


FiG.  201. 


sens  the  danger  of  irritation  from  the  motion  imparted  by  the  file  to 
the  teeth  which  are  not  firmly  set  in  their  sockets.  Some  use  for  this 
purpose  plaster ;  but  we  think  the  gutta  percha,  or  modeling  compo- 
sition, as  suggested  by  Prof.  Gorgas,  will  be  found  altogether  more 
conveniently  applied  and  more  agreeable  to  the  patient. 

When  the  file  is  employed  for  separating  the  superior  incisors  and 
cuspids,  the  operation  may  be  completed  with  a  beveled-edge  file,  as 
no  sharp  angle  should  be  left  near  the  gum. 

In  separating  the  bicuspids  by  filing,  a  space  should  be  made  some- 
what in  the  form  of  the  letter  v  ;  it  should  not,  however,  form  an  acute 
angle  at  the  gum.  This  space  should  also  be  slightly  wider  toward 
the  palatal  and  lingual  surfaces.  For  its  formation,  a  v-shaped  file, 
which  is  one  beveled  on  both  sides,  will  be  found  most  suitable.  A 
space  shaped  in  this  manner  will  prevent  the  approximation  of  the 


TREATMENT   OF   DENTAL   CARIES. 


413 


sides  of  the  teeth,  and  if  filling  be  necessary, it  will  enable  the 
to  do  it  in  the  most  perfect  manner. 

Fig.   202    represents 
Fig.  202.         knife-edge   or   bicuspid 
pointed  and  blunt  files. 

Fig.  203  represents  a 
file  designed  by  Dr.  E. 
Parmly  Brown,  for  con- 
touring the  approximal 
surfaces  of  molars  and 
bicuspids.  It  is  three- 
sided,  and  cut  on  all  sides. 

When  the  separation  of  the  molar  teeth 
in  this  manner  becomes  necessary,  the  same 
shaped  space  should  be  formed.  But  as 
these  teeth  are  situated  far  back  in  the 


operator 


nilmjipj 


mouth,  it  cannot  often  be  done  with  a  straight  file ;  to  obviate  this 
difficulty,  an  instrument,  with  which  every  dentist  is  acquainted, 
denominated  a  file-carrier,  is  usually  employed. 


414 


DENTAL,  SURGERY. 

Fig.  205. 


TREATMENT   OF   DENTAL   CARIES. 


415 


Fig.  209. 


Fig.  208. 


Fig.  20-4  represents  Dr.  J.  E.  Line's  file-carrier,  which  is  simple  in 
its  construction,  as  well  as  very  serviceable. 

Fig.  205  represents  Dr.  W.  B.  Miller's  file-carrier,  with  three  heads, 
as  shown,  which  admits  of  changing  direction  and  slant  very  quickly. 

Fig.  206  represents  a  cheap  and  simple  file-carrier,  the  device  of  Dr. 
D.  M.  Clapp,  either  straight  or  curved,  which  will  carry  a  thin  sepa- 
rating file,  and  also  finer  ones  for  cutting  metal. 

A  file-carrier  attachment  for  use  with  the  dental  engine,  has  also 
been  devised,  but  is  not  so  readily  controlled  as  the  hand  instrument. 

A  great  variety  of  v-shaped  separating  files  are  now  to  be  found  in 
the  dental  depots,  from  English,  French,  and  American  manufacturers. 
Fig.  207  will  give  a  correct  idea  of  some  of  these  shapes. 

Disks  composed  of  difl^erent  substances,  and  attached  to  mandrels, 
for  use  with  the  dental 
engine,  are  employed  for 
separating  teeth  that 
are  affected  with  super- 
ficial caries  on  their 
proximate  surfaces. 
Figs.  208  and  209  rep- 
resent the  diamond  disk, 
composed  of  a  thin  plate 
of  metal,  such  as  nickel, 
in  which  diamond  pow- 
der is  thoroughly  incorporated.  The  corundum  disks,  Fig.  210,  intro- 
duced by  the  late  Dr.  Robert  Arthur,  of  Baltimore,  are  now  used,  to 
the  almost  entire  exclusion  of  files,  in  separating  teeth,  especially 
molars  and  bicuspids.  Although  often  employed  for  separating  the 
incisor  teeth,  they  are  not  so  pj^  210 

well  adapted  for  such  deli- 
cate operations,  on  account  of 
being  less  readily  controlled 
than  the  chisel  or  file.  The 
incisor  teeth,  being  much 
smaller  than  the  posterior 
teeth,  should  never  be  cut  in 
the  same  proportion.  When  the  disk  is  used  for  separating  the  an- 
terior teeth,  the  greatest  care  should  be  exercised  to  avoid  too  much 
cutting,  especially  of  the  labial  angles. 

These  disks  are  similar  in  composition  to  the  ordinary  corundum 
wheels  used  for  grinding  porcelain  teeth,  being  composed  of  emery 
powder  and  gum  shellac,  which,  being  softened  by  heat,  is  rolled  into 
a  great  variety  of  shapes  to  suit  the  different  operations  to  be  per- 


416 


DENTAL  SUEGERY. 


Fir,.  211.  formed  by  them.  The  disks 

thus  formed  are  mounted 
on  mandrels  (Fig.  212),  for 
use  with  the  dental  engine, 
an  instrument  which  will 
hereafter  be  described. 

Fig.    211    represents    a 
few   forms   of  Dr.  A.   L. 
Northrop's  corundum  points  for  cutting  and  polishing. 

Fig.  212  represents  different  forms  of  mandrels,  with  and  without 
shoulders,  for  mounting  corundum,  diamond,  rubber,  celluloid,  box- 
wood, emery-paper,  sand-paper  and  cuttle-fish  paper,  disks  and  points. 

Fig.  212. 


After  a  sufficient  portion  of  the  tooth  has  been  cut  away,  the  surface 
should  be  made  as  smooth  as  possible,  with  a  very  fine  or  half-worn  file, 
or  with  Arkansas,  Hindostan  or  Scotch  stones,  wood  polishing  points, 
disks  of  soft  or  hard  rubber,  boxwood,  felt,  emery,  sand,  or  cuttle-fish 
paper,  carrying  powders  such  as  pumice,  silex,  emery,  buck-horn,  co- 
rundum flour,  Hindostan,  Arkansas,  etc.,  etc.,  or  with  tape  charged 
with  such  powders. 


Fig.  213. 


Fig.  214. 


Fig.  213  represents  hard  rubber  disks,  for  carrying  powders  for  pol- 
ishing the  natural  teeth  and  finishing  fillings. 

Fig.  214  represents  boxwood  disks. 

Fig.  215  represents  corrugated  soft  rubber  disks  and  points  for  car- 
rying powders  for  polishing. 

Fig.  216  represents  emery,  sand,  and  cuttle-fish  paper  disks. 


TREATMENT   OF   DENTAL   CARIES. 
Fir.  215. 


417 


B^iG.  216. 


x!ifi!!l!%x 


/ 


Fig.  217. 


Fig.  217   represents   points   of  Arkansas,  Hiudostan    and   Scotch 
stones  mounted  on  mandrels  for  polishing  the  natural  teeth  and  fillings. 

Fig.  218  represents  wood  polishing  points,  which  are  screwed  into  a 
mandrel  for  use  with  the  dental  engine.     These  points  are  also  ser- 
viceable for  removing  discoloration  from  the  teeth,  such  as  results  from 
depositions  of  calculus. 
27 


418 


DENTAL   SURGERY. 


Dr.  George  H.  Cushing's  Changeable  Angle  Disk  Carrier,  Fig.  219, 
is  easily  attached  and  removed  from  the  dental  engine  hand-jMece,  its 
angular  range  being  indicated  by  the  dotted  lines. 

A  fountain  mouth  protector  (Fig.  220),  while  protecting  the  tongue 
and  cheek  from  injury,  serves  also  to  keep  the  disk  wet.  A  supply  of 
water  is  stored  in  the  rubber  bulb  of  reservoir  b,  by  compressing  and 
immersing  it  in  water,  and  is  fed  as  required  through  the  small  aperture 
seen  in  the  cuts  by  a  touch  of  the  finger  on  the  bulb.  The  tube  A  is 
sprung  over  the  hand-piece,  and  may  be  turned  for  use  in  any  part  of 
the  mouth. 

Fig.  221  represents  Dr.  F.  Herrick's  fountain  drip-point,  intended 


Fig.  219 


for  keeping  up  a  continuous  dripping  of  water  upon 
corundum  points,  engine  burrs,  and  other  rapidly 
revolving  instruments. 

When  removing  superficial  caries,  all  edges  and 
sharp  corners  should  be  rounded  and  made  smooth, 
and  when   the  operation   is   completed  the  patient 
i(|llljl     g        should  be  directed  to  keep  the  excised  surfaces  of 
A  tooth  structure  perfectly  clean,  for  if  the  secretions 

of  the  mouth  or  extraneous  matter  be  permitted  to  adhere  to  such 
surfaces,  a  recurrence  of  the  disease  will  take  place.  Prior  to  removing 
superficial  caries  from  the  approximal  surfaces,  and  especially  of  the 
front  teeth,  such  teeth  may  be  separated  by  pressure  made  with  wood, 
cotton,  tape  or  rubber,  so  that  unnecessary  cutting  of  enamel  may  be 
avoided,  and  but  little  more  of  the  tooth  structure  be  removed  than 
the  decalcified  part.  When  a  portion  of  the  approximal  surface  of 
a  tooth  is  cut  away,  the  excised  surface  should  be  left  free  and 
exposed  to  the  friction  of  the  tongue  and  lips,  which  will  prevent 
food  and  other  extraneous  matters,  as  well  as  the  secretions  of  the 
mouth  from  lodging  and  remaining  in  contact  with  it.  The  portion 
cut  away  should  be  as  much  as  is  possible  from  the  posterior  part  of 


TREATMENT   OF   DENTAL,   CAIHES.  419 

the  approxiraal  surface,  especially  in  the  case  of  the  front  teeth,  so 
as  to  prevent  any  noticeable  disfigurement.  When  superficial  caries 
is  located  on  the  approximal  surfaces  of  the  bicuspids  and  molars, 
and  near  to  the  grinding  surfaces,  it  may  be  removed  by  cutting  out 
a  V-shaped  space  between  such  teeth.  When  enamel  chisels  are 
employed  for  removing  superficial  caries,  the  instrument  should  be 
grasped  near  its  cutting  edge,  which  should  be  applied  in  the  line 
of  the  enamel  fibres,  using  the  adjoining  tooth  as  a  fulcrum  for 
the  thumb,  in  order  to  prevent  the  instrument  from  slipping  and 
wounding  the  soft  part  adjacent.  Having  in  such  a  manner  removed 
the  overhanging  enamel,  the  softened  or  decalcified  dentine  should  be 
cut  away  with  a  scoop-shaped  excavator,  the  use  of  which  will  also  de- 
termine the  depth  to  which  the  caries  has  penetrated,  and  if  not  too 
extensive,  the  enamel  chisel  can  again  be  employed  until  the  surface 
is  made  level  or  uniform.  All  edges  and  sharp  corners  should  be 
rounded  and  made  smooth,  and  it  may  be  necessary,  in  order  to  com- 
plete the  cutting  process,  to  use  a  curved  fiiie-cut  file.  Corundum  disks 
operated  with  the  dental  engine  may  be  found  more  convenient  for  the 
removal  of  superfiicial  caries,  and  especially  in  the  case  of  the  bicuspids 
and  molars,  to  be  followed  by  strips  of  emery  cloth,  or  paper  of  the  fine 
grades ;  also  disks  of  fine  sand-paper.  When  a  perfectly  smooth  and 
normal  surface  is  obtained,  it  should  be  highly  polished  with  pulverized 
pumice,  or  silex  applied  on  linen  tape,  or  on  disks  of  flexible  rubber, 
boxwood,  or  celluloid,  completing  the  operation  with  polishing  putty 
(peroxide  of  tin).  The  corundum  and  Arkansas  or  Hindostan  stone 
points,  followed  by  the  use  of  wood  points  for  the  application  of  the 
polishing  putty,  will  be  found  useful  for  removing  superficial  caries 
from  exposed  surfaces.  When  the  operation  of  removing  superficial 
caries  is  completed,  the  patient  should  be  directed  to  keep  the  excised 
surface  of  tooth  structure  perfectly  clean.  Caries  upon  the  approximal 
surfaces  of  the  teeth  may  be  prevented  by  occasionally  polishing  such 
surfaces,  and  passing  floss  silk  between  the  teeth  in  connection  with  the 
use  of  the  tooth-brush. 

Since  the  introduction  of  the  dental  engine,  the  removal  of  superfi- 
cial caries,  and  the  preparation  of  the  excised  surface  can  be  very 
effectively  performed  ;  and  it  should  be  remembered  that  such  a  surface 
should  be  left  self-cleansing,  so  that  deleterious  substances  may  not 
lodge  and  remain  in  contact  with  it. 

For  separating  the  teeth  to  obtain  space  for  the  free  use  of  the  in- 
struments employed  in  preparing  and  filling  cavities  on  the  approximal 
surfaces,  the  reader  is  referred  to  the  "  Treatment  of  Deep-seated  Caries." 

Separation  of  the  Teeth. — Before  a  cavity  can  be  prepared  in 
the  approximal  surface  of  a  tooth,  it  is  usually  necessary  to  separate  it 


420  DENTAL   SURGERY. 

from  the  adjoining  one.  This  may  be  done  either  with  a  file,  enamel 
chisel,  corundum  disk,  or  by  the  pressure  of  some  interposed  elastic 
substance,  or  by  wedges  of  wood  driven  between  the  teeth,  or  by 
metallic  wedges  or  separators.  Each  of  these  methods  has  its  advan- 
tages. When  caries  has  extended  over  nearly  the  whole  approximal 
surface,  so  that,  after  the  removal  of  the  diseased  part,  the  orifice  of 
the  cavity  will  be  surrounded  by  a  thin,  brittle,  and  irregular  wall,  the 
former  is  the  preferable  method  ;  especially  in  individuals  having  a 
decided  scorbutic  tendency,  or  who  have  suflfered  from  the  use  of 
mercurial  medicines  or  syphilitic  disease,  and  in  aged  persons.  But 
when  the  caries  has  spread  over  only  a  small  portion  of  the  surface  of 
the  tooth,  and  is  surrounded  by  sound,  healthy  enamel,  the  latter 
method  should  be  adopted  ;  especially  in  individuals  in  whom  there  is 
no  manifest  tendency  to  inflammation  or  sponginess  of  the  gums,  and 
in  young  subjects.  The  manner  of  separating  teeth  with  a  file  has 
been  already  described ;  it  will  only  be  necessary,  therefore,  in  this 
place,  to  offer  a  few  remarks  on  separating  by  pressure,  which  was  first 
adopted  by  Dr.  Eleazer  Parmly. 

The  following  are  its  advantages,  where  it  can  be  resorted  to  with 
safety  :  after  the  removal  of  the  pressure,  the  teeth  almost  immediately 
come  together,  leaving  no  space  to  injure  their  beauty ;  what  is  of  still 
greater  importance,  the  dentine  around  the  external  surface  of  the 
filling  is  not  exposed  to  the  action  of  the  secretions  of  the  mouth,  or 
other  agents  capable  of  exerting  upon  it  a  deleterious  action.  On  the 
other  hand,  some  are  of  opinion  that  when  the  teeth  come  together 
again  a  lodgment  is  aflTorded  to  corrosive  agents,  upon  the  presence  of 
which  the  disease  was,  in  the  first  instance,  produced,  and  which  would 
soon  cause  a  recurrence  of  it.  In  replying  to  this  objection,  it  is  only 
necessary  to  observe,  that  the  parts  of  teeth  first  attacked  by  caries 
were  the  points  in  contact  with  each  other,  where  the  enamel  may  be 
supposed  to  have  sustained  some  injury  by  pressure,  thus  rendering 
them  more  vulnerable  at  these  points  to  the  action  of  the  causes  that 
produced  the  disease.  By  properly  replacing  the  diseased  parts  with 
gold,  the  external  surfaces  of  the  fillings  will  be  the  only  parts  that 
come  in  contact  with  each  other ;  and  if  of  gold  will  not  be  liable  to 
injury  from  the  above-mentioned  mechanical  causes.  The  enamel 
around  the  fillings,  if  proper  attention  to  cleanliness  be  observed,  is  not 
so  liable  to  be  acted  on  by  chemical  agents  as  the  dentine  which  the 
file  would  expose. 

But  teeth  cannot  always  with  impunity  be  separated  by  pressure ;  it 
can  only  be  done  with  safety  in  certain  cases.  As  a  general  rule,  the 
writer  is  of  the  opinion  that  it  ought  not  to  be  attempted  after  the 
thirtieth  or  fortieth  year  of  age,  though  it  may  sometimes  be  done  with 


TREATMENT    OF    DENTAL    CARIES.  421 

safety  at  even  a  later  period.  The  diseased  action  excited  for  the  time 
iu  the  sockets  of  the  teeth  does  not  so  readily  subside  at  a  later  age ; 
and  it  has  in  some  instances  been  known  to  result  in  the  loosening  and 
ultimate  loss  of  the  organs.  In  one  case  which  came  under  the 
observation  of  the  author,  the  inflammation  extended  to  the  pulp, 
causing  its  disorganization,  and  the  consequent  death  of  the  tooth. 

The  pressure  ought  never  to  be  too  actively  exerted  ;  it  should  be 
gradual  and  constant.  From  three  to  five  days  are  usually  required 
for  the  separation  of  two  teeth  sufficiently  for  the  removal  of  the  de- 
cayed part  and  the  introduction  of  a  filling.  After  they  have  been 
separated  in  this  "way,  they  should  be  kept  apart,  without  any  increase 
of  pressure,  until  the  soreness  in  the  cavities  shall  have  subsided, 
before  any  further  steps  are  taken  in  the  operation.  Cotton  saturated 
with  sandarach  varnish,  or  white  gutta-percha,  may  be  used  to  retain 
teeth  after  being  separated  with  other  substances,  or  by  the  rapid 
method.  Only  two  teeth  should  be  separated  in  the  front  part  of  the 
mouth,  in  the  same  jaw,  at  the  same  time.  As  soon  as  the  cotton  or 
tape,  or  other  substance  used  to  separate  teeth,  has  affi)rded  the  desired 
space,  it  should  be  removed,  and  the  space  retained  for  one  or  two  days 
by  cotton  saturated  with  sandarach  varnish,  or  white  gutta-percha, 
or  one  of  the  zinc  filling  materials,  pressed  between  them,  when  the 
teeth  may  be  well  enough  to  permit  of  being  operated  on. 

The  pressure  is  usually  made  by  introducing  between  the  crowns  of 
two  teeth  a  thin  wedge  of  soft  wood,  a  piece  of  India-rubber,  tape,  a 
little  raw  cotton  or  ligatures,  replacing  the  first-named  substances  every 
day  or  two  with  thicker  pieces.  While  some  prefer  India-rubber  to 
any  other  substance  employed  for  the  purpose,  the  object  may  be 
readily  attained  with  other  substances.  Cotton  or  tape  pressed  firmly 
between  the  teeth  and  renewed  daily,  also  gutta-percha,  will  in  the 
course  of  a  few  days  separate  teeth,  and  with  less  soreness  than  India- 
rubber,  to  the  use  of  which  many  object,  on  account  of  the  irritation 
it  causes.  Many  operators  prefer  gradual  pressure  in  separating  teeth, 
but  others,  on  account  of  economy  of  time,  consider  it  better  for  the 
separation  to  be  made  at  once,  and  not  prolonged  through  several  days. 
It  is  also  urged  that  the  patient  suffers  less,  and  that  there  is  also  less 
danger  to  the  teeth,  in  rapid  separation  than  where  this  process  is 
gradual.  The  degree  of  pressure,  and  the  method  by  which  the  sepa- 
ration is  to  be  accomplished,  should,  however,  be  determined  by  the 
susceptibility  of  the  parts  to  inflammation.  The  operation  of  rapidly 
separating  the  teeth  consists  in  the  use  of  two  wedges  of  fine-grained 
wood,  either  orange  or  boxwood.  The  first  wedge  is  forced  between 
the  necks  of  the  teeth,  care  being  taken  not  to  lacerate  the  gum,  while 
the  second  wedge,  which  tapers  more  than  the  first,  is  inserted  between 


422 


DENTAL   SUEGERY. 


the  points  of  the  teeth,  the  wedges  heing  driven  alternately  by  mallet 
force,  until  sufficient  space  is  obtained,  when  the  second  wedge  is 
removed.  Very  great  care  should  be  exercised  in  driving  the  second 
wedge  between  the  points  of  the  teeth,  on  account  of  the  force  ex- 
erted by  it.  This  description  applies  to  the  front  teeth,  as  it  is  not 
advisable  to  attempt  the  separation  of  the  molar  teeth  in  this  manner. 

Fig.  222. 


Fig.  222  represents  a  set  of  the  Jarvis  Separators,  by  means  of  which 
adjacent  teeth  can  be  forced  apart  without  delay,  or  appreciable  pain  to 
the  patient.  This  separator  consists  of  a  piece  of  steel,  nickel-plated, 
bent  upon  itself,  having  the  two  ends  formed  to  fit  the  outer  portions 
of  the  approximal  surfaces  of  two  adjoining  crowns.     These  jaws  are 


TREATMENT   OF   DENTAL  CARIES. 


423 


forced  apart  by  the  action  of  the  screw  which  passes  through  one  and 
against  the  other.     The  compound  forms  consist  of  two  wedges  ap- 


proaching or  passing  each 
other,  and  are  applicable  to 
the  incisor  teeth,  the  first 
forms  being  applicable  to  the 
bicuspid  and  molar  teeth. 

Fig.  223  represents  Chase's 
Dental  Wedge  Forceps,  by 
which  wooden  wedges  can  be 
forced  between  adjacent  teeth 
for  the  purpose  of  separating 
them,  and  by  the  use  of  this 
appliance  it  is  claimed  that 
there  is  less  danger  of  irrita- 
tion and  subsequent  inflam- 
mation than  by  the  method 
of  driving  a  wedge  with  the 
hand-mallet. 

Dr.  Corydon  Palmer  recom- 
mends the  following  method 
of  rapid  wedging :  A  wedge 
made  from  a  thin  piece  of 
wood  or  quill  is  first  intro- 
duced between  the  teeth,  to 
protect  the  gum.  Next  to 
the  first  wedge,  a  square, 
tapering  one,  of  orange  or 
boxwood,  is  introduced  at  the 
gum,  in  such  a  manner  as 
not  to  interfere  with  the  view 
of  the  wall  of  the  cavity,  and 
which  is  permitted  to  remain 
during  the  operation  of  filling, 
being  driven  to  hold  the  space 
gained  by  a  broad  wedge,  in- 
troduced by  hand-pressure  or 
mallet  force  between  the  cut- 
ting edges  of  the  teeth,  its 
point  being  directed  toward 
the  gum.  The  separation  is 
gradually  accomplished,  in 
order  to  allow  the  tissues  to 


Fig.  223. 


424 


DENTAL   SUEGERY. 


accomraodate  themselves  to  the  pressure  to  which  they  are  subjected. 
It  is  recommended  that  the  rapid  process  for  separating  teeth  be 
restricted  to  cases  where  but  little  space  is  required,  and  where  the 
structures  are  soft  and  spongy.  Fig.  224  represents  a  wedge-cutter, 
for  removing  the  projecting  portions  of  the  wooden  wedges. 

After  separating  teeth  by  rapid  wedging,  the  wooden  wedges  should 
not  be  permitted  to  remain  between  the  teeth,  when  more  than  one 
sitting  is  necessary  to  complete  the  operation  of  filling,  but  removed, 
and  the  space  maintained  by  cotton  saturated  with  sandarach  varnish 
or  by  gutta  percha,  until  the  next  sitting. 

There  is  a  difference  of  opinion  among  many  prominent  and  skillful 
operators,  in  regard  to  the  permanent  separation  of  the  teeth;  the 
advocates  of  contour  fillings  objecting  to  the  removal  of  so  much  tooth 
substance  without  substituting  for  it  a  non-destructible  substance,  such 

Fig.  224. 


as  gold,  while  the  advocates  of  the  permanent  separation  method  con- 
tend that  self  cleansing  surfaces,  properly  prepared,  are  preferable  to 
the  labor,  pain,  time,  expense  and  general  strain  for  both  patient  and 
operator  in  perfecting  contour  work. 

Dr.  T.  F.  Chupein,  an  advocate  of  the  permanent  separation  of  the 
teeth,  describes  his  method  as  follows: — 

"The  mode  of  treating  the  upper  incisors  and  cuspids  is  indicated 
by  the  following  diagram.  Fig.  225. 

It  will  be  noticed  that  there  are  semi-lunar  spaces  cut  from  the 
palatal  surfaces  of  each  tooth.  These  spaces  are  cut  for  the  removal 
of  incipient  decay,  for  its  anticipation  as  well  as  to  obtain  room  to  fill 
when  decay  is  deep-seated.  To  make  these  spaces  without  mutilating 
the  outer  faces  of  the  teeth,  we  proceed  as  follows:  Two  teeth  are 
well  wedged  apart  by  the  introduction  of  wooden  wedges,  floss  cotton 


TREATMENT   OF   DENTAL   CARIES. 


425 


or  rubber,  whichever  seems  best  to  the  operator.  When  separated 
about  the  thirty-second  of  an  inch  or  more,  a  thin  disk  is  used  on  the 
dental  engine.     The  Arthur  disk,  D,  is  about  the  proper  size,  and  this 

Fig.  225. 


is  used  on  the  palato-mesial  and  distal  aspects  of  the  teeth  being 
operated  on,  and  the  cutting  so  shaped  that  the  outer  faces  of  the  teeth 
are  not  encroached  upon.  After  the  enamel  from  these  surfaces  is 
removed,  a  curved  file,  like  the  following,  may  be  used  to  curve  out 

Fig.  226. 


Fig.  227. 


the  surface  begun  by  the  disk,  or,  what  is  still  better,  a  small  corundum 
point,  mounted  on  the  right-angle  attachment  of  the  dental  engine, 
and  applied  between  the  two  teeth  to  be  ope- 
rated on  ;  the  head  of  the  patient  being  well 
thrown  back,  so  that  these  surfaces  may  be 
readily  reached.  Should  either  of  the  teeth 
thus  separated  need  filling,  the  filling  should 
be  done  at  once,  as  more  room  is  had  now, 
than  if  the  teeth  are  permitted  to  fall  back 
into  their    old    places.     When  two   are   thus 

separated  (and  filled,  if  they  need  filling),  two  more  are  wedged  apart, 
and  the  spaces  cut,  as  has  been  described." 

Concerning  the  treatment  of  the  bicuspids  and  molars,  Dr.  Chupein 
says : — 

"  These  teeth  are  so  concealed  by  the  lips,  that  even  when  pretty 
wide  separations  are  made  between  them  they  present  no  revelation  of 
their  having  been  operated  upon  at  all.  To  separate  the  molars  and 
bicuspids,  we  do  not  wedge  them  apart,  as  we  recommend  the  incisors 
and  cuspids  to  be  done  (although  it  would  be  no  detriment  to  do  so), 
but  we  leave  the  teeth  in  the  relation,  one  to  the  other,  that  we  find 
them,  and  separate  them,  so  as  to  leave  a  small  point  of  contact  near 
the  gum  margin.     This  point  of  contact,  though  minute,  is  sufficient 


426  DENTAL  SURGERY. 

to  keep  the  surfaces  that  have  been  deprived  of  the  enamel  by  the 
disk  or  file  from  again  approaching  each  other,  and  also  serves  to 
protect  the  gum  from  being  irritated  by  the  impaction  of  food.  Fig. 
228  will  illustrate  this  idea. 

It  will  be  seen  that  the  filed  surfaces  are  entirely  kept  apart,  and 
that  though  the  tooth  may  change  its  position  or  turn  in  its  socket 
(which  is  not  likely),  the  cut  surfaces  would  be  still  kept  from  close 
proximity.  It  also  permits  a  free  space,  which  is  readily  kept  clean 
by  simply  rinsing  the  mouth.  We  fear  that  it  is  the  careless  manner 
in  which  this  operation  has  been  performed  that  has  brought  it  into 
disrepute,  and  which,  from  this  carelessness,  has  made  many  who  tried 
the  system  abandon  it  as  being  iueflfectual,  when  the  fault  lay  more  in 
the  manner  of  its  performance  than  in  the  integrity  of  the  operation. 
Particular  stress  must  be  laid  on  the  non-removal  of  this  point  of  con- 
tact, otherwise  the  operation  becomes  inefiective.  Indeed,  if  it  is 
removed,  we  consider  that  the  operation  would  be  worse  than  if 
nothing  at  all  had  been  done.  To  make  it  entirely  efiective,  it 
should  be  done  in  anticipation  of  decay,  or  when  decay  is   in   its 

Fig.  228.  Fig.  229. 


first  stages — when  it  has  not  or  scarcely  has  pierced  the  enamel. 
If  attempted  later,  the  very  point  of  contact  we  wish  to  preserve 
will  be  encroached  on  by  decay,  or  completely  destroyed  by  it. 
If  in  anticipation  of  decay,  the  cutting  need  be  done  only  from  one 
tooth,  and  that  from  the  mesial  surface  of  the  furthest  back  tooth, 
Fig.  229  will  illustrate  this. 

We  would  recommend  that  after  the  teeth  are  separated  a  waxed 
thread  be  passed  through  the  separations  down  to  the  gum,  and  that 
this  should  pass  the  point  of  contact  easily,  and  with  a  snap,  to  indicate 
that  the  teeth  are  just  held  apart,  but  yet  touch  sufiiciently  that  their 
relation,  one  to  the  other,  should  not  have  been  changed.  The  thread 
or  silk  thus  used  should  not  be  frayed.  This  would  indicate  roughened 
edges  of  enamel  or  too  close  contact.  If  the  former,  it  should  be 
polished  or  cut  smooth ;  if  the  latter,  the  point  of  contact  should  be 
lessened  so  that  the  string  will  pass  through  readily  and  with  a  snap. 
We  recommend,  too,  that  the  rubber  dam  be  applied  on  these  teeth 
after  these  separations  are  made.     It  will  often  appear  that  all  decay 


TREATME^'T   OF   DENTAL   CARIES. 


427 


has  been  removed.  This  deception  is  caused  by  the 
gloss  left  on  the  cut  surfaces  by  the  saliva,  but  when  the 
dam  is  applied,  and  the  surfaces  dried  and  critically 
examined,  we  can  know  for  certain  if  all  the  disor- 
ganized tissue  has  been  removed  or  not. 

We  proceed  to  make  these  separations  by  arming  the 
dental  engine  with  a  disk  like  that  represented  at  Fig. 
225°.     We  cut  the  teeth  throuo-h  from  their  buccal  to 


Fig.  231. 


Fig.  230 


mh 


ill 


Fig.  232. 


Fig.   234. 


Fig.  235. 


their  palatal  aspect,  if  in  the  upper,  and  from  their  buccal  to  their 
lingual  aspect  if  in  the  lower  jaw.  We  stop  from  time  to  time  as  we 
proceed,  to  see  if  we  have  not  gone  too  far.  When  nearly  down  to 
the  point  of  contact,  near  the  gum,  we  stop  with  the  engine  and  finish 


428  DENTAL,   SURGERY. 

with  a  file  having  a  round  edge,  like  Fig.  230 ;  or,  in  case  of  molar 
teeth,  with  a  file  like  Fig.  231.  When  finished,  the  buccal  aspects  of 
the  teeth  have  the  appearance  represented  by  Fig.  232,  whilfe  the  teeth 
viewed  from  their  masticating  surfaces  are  represented  by  Fig.  233. 

Should  it  be  found  necessary  to  fill  the  teeth  thus  separated,  an  easy 
approach  to  the  cavity  is  had,  and  the  fillings,  as  well  as  the  filed  sur- 
faces can  be  left  highly  polished. 

The  class  of  teeth  shown  at  Fig.  234  are  such  as  we  recommend  to 
be  treated  as  we  have  described,  for  they  present  broad  surfaces  of 
contact  on  their  buccal,  masticating  and  palatal  aspects,  and  are  thus 
rendered  more  prone  to  decay  from  the  ready  lodgment  of  particles  of 
food  between  them. 

The  other  class  of  teeth,  represented  by  Fig.  235,  rarely  decay,  be- 
cause, as  will  be  seen,  they  touch  only  by  minute  points  of  contact, 
and  are  thus  not  liable  to  decay.  We  do  not  recommend  teeth  of  this 
form  to  be  separated.  If  they  decay  they  should  be  wedged  apart  and 
filled,  and  allowed  to  fall  back  in  their  old  position.  Decay  in  teeth 
of  this  class  will  generally  be  found  above  the  point  of  contact  toward 
the  gum.  Should  permanent  separation  be  attempted  with  teeth  of  this 
class  it  might  prove  ruinous,  or  if  effective,  the  teeth  must,  from  their 
shape,  be  considerably  mutilated  and  cut  away,  to  prevent  the  cut  sur- 
faces from  again  falling  in  close  apposition.  Judgment,  therefore, 
must  be  used  in  the  separation  of  the  teeth,  although,  as  we  have  said, 
the  operation  is  comparatively  simple. 

But  whether  the  teeth  be  separated  with  cutting  instruments  or  by 
pressure,  the  space  should  be  sufiiciently  wide  to  enable  the  dentist  to 
operate  with  ease,  otherwise,  it  will  be  impossible  to  remove  the  caries 
and  fill  the  teeth  in  a  proper  manner. 

TREATMENT   OF    DEEP-SEATED    CARIES. 

Filling  teeth  is  one  of  the  most  difficult  operations  the  dentist  is 
called  upon  to  perform  ;  it  often  baffles  the  skill  of  operators  who  have 
been  in  practice  many  years.  It  is  advisable  only  under  certain  cir- 
cumstances, and  when  the  operation  is  performed  without  due  regard 
to  these,  it  may  be  productive  of  injury  rather  than  benefit.  It  is  the 
only  certain  remedy  that  can  be  applied  for  arresting  the  progress  of 
deep-seated  caries  ;  but  to  be  effective,  it  must  be  executed  in  the  most 
thorough  and  perfect  manner.  The  preservation  of  a  tooth  may  be 
regarded  as  comparatively  certain  when  well  filled,  and  with  a  suitable 
material,  if  it  be  afterward  kept  constantly  clean.  At  any  rate,  it  is 
not  likely  ever  again  to  be  attacked  by  caries  in  the  same  place. 

On  this  highly  important  operation.  Dr.  E.  Parmly  thus  remarks  : 
"  If  preservation  is  as  good  as  a  cure,  this  is  as  good  as  both ;  for  the 


TREATMENT   OF   DENTAL   CARIES.  429 

operation  of  filling,  when  thoroughly  performed,  is  both  preservation 
and  cure.  And  yet  it  must  never  be  forgotten,  that  this  assertion  is 
true  only  in  those  instances  in  which  the  operation  is  well  and  properly 
done  ;  and  perhaps  it  is  imperfectly  and  improperly  performed  more 
frequently  than  any  other  operation  on  the  teeth. 

"  There  are  reasons  for  this  fact,  into  which  every  ambitious  and 
honorable  practitioner  will  carefully  inquire.  Although  the  books 
are  explicit  on  this  point,  I  deem  it  sufficiently  important  to  deserve  a 
few  additional  remarks.  The  following  considerations  are  essential, 
and,  therefore,  indispensable  to  success  in  this  department  of  practice. 
Firstly.  The  instruments  used  must  be  of  the  proper  construction  and 
variety.  Secondly.  The  material  employed  must  be  properly  prepared 
as  well  as  properly  introduced.  Thirdly.  The  cavity  which  receives 
the  filling  must  be  so  shaped  as  to  retain  it  in  such  a  manner  as  to 
exclude  not  only  solids,  but  all  fluids,  and  even  the  atmosphere  itself. 
Fourthly.  The  surface  of  the  filling  must  be  left  in  such  condition  as  to 
place  it  beyond  the  reach  of  injury  from  food  and  other  mechanical 
agents  with  which  it  necessarily  comes  in  contact.  Fifthly.  The  tooth 
thus  filled  should  be  free  from  pain  and  every  known  cause  of  internal 
inflammation." 

It  is  important  that  the  operation  be  performed  before  the  disease 
has  reached  the  pulp  cavity ;  after  this,  the  permanent  preservation  of 
the  tooth  may  be  regarded  as  more  or  less  questionable.  Still,  under 
favorable  circumstances,  the  author  believes  it  may,  in  the  majority  of 
cases,  be  performed  with  success.  But,  as  the  propriety  and  manner 
of  filling  a  tooth  after  the  pulp  has  become  exposed  will  hereafter  come 
up  for  special  consideration,  as  well,  also,  as  the  operation  of  filling  the 
pulp  cavity  after  the  destruction  of  the  pulp,  it  will  not  be  necessary 
to  enlarge  upon  these  subjects  at  this  time. 

Materials  Employed  for  Filling  Teeth. — Among  the  articles 
which  have  been  employed  for  filling  teeth,  are  gold,  platina,  silver, 
tin,  lead;  fusible  alloys  of  tin,  lead,  bismuth,  and  cadmium;  amalgams, 
guttarpercha,  oxychloride  of  zinc,  oxyphosphate  of  zinc,  and  various 
preparations  of  the  gum  resins.  Of  these  no  single  one  can  be  said  to 
unite  all  the  requirements  of  a  perfect  material  for  filling,  which  may 
be  enumerated  :  1.  Resistance  to  the  mechanical  action  of  mastication. 
2.  Resistance  to  the  chemical  action  of  the  mouth.  3.  Facility  of  in- 
troduction and  consolidation.  4.  Harmony  of  color.  5.  Absence  of  all 
galvanic,  chemical,  or  vital  action  upon  the  teeth  or  the  general  system. 
6.  Absence  of  all  heat-conducting  property.    7.  Absence  of  shrinkage. 

Gold  Foil. — To  the  use  of  this  material,  when  properly  prepared, 
there  is  the  least  possible  objection ;  perfectly  answering  the  first,  second, 
fifth,  and  seventh  requirements ;  to  a  great  extent  the  third,  if  in  skillful 


430  DENTAL   SURGERY. 

hands ;  but  deficient  in  the  fourth  and  sixth.  No  better  material  is 
wanted  for  the  operation.  A  tooth  may  be  so  filled  with  it  as  to  secure, 
in  almost  every  case,  its  permanent  preservation.  It  should,  however, 
be  perfectly  pure,  be  beaten  into  thin  leaves,  and  well  annealed  by  the 
manufacturer,  before  it  is  used.  When  prepared  in  this  manner,  it  may 
be  pressed  into  all  the  inequalities  of  the  cavity,  and  rendered  so  firm 
and  solid  as  to  be  impermeable  to  the  fluids  of  the  mouth. 

Although  there  may  be  no  difference  in  the  purity  of  the  gold  and 
the  thickness  of  the  leaves,  yet  a  marked  difference  will  be  found  to 
exist  in  the  malleability  and  toughness  of  the  foil  of  different  beaters. 

The  art  of  preparing  gold  for  filling  teeth  is  an  exceedingly  nice  and 
difficult  one,  and  is  believed  to  have  attained  greater  perfection  in  the 
United  States  than  in  any  other  country  ;  at  least,  this  fact  is  so  generally 
admitted,  that  many  of  the  most  eminent  European  practitioners  pro- 
cure nearly  all  they  use  from  America.  (See  process  of  manufacture 
in  Harris'  Med.  and  Dent.  Dictionary.) 

The  principal  preparations  of  gold  used  for  filling  teeth  are  the  non- 
cohesive,  the  cohesive,  and  the  sponge  or  crystal  gold. 

Non-cohesive  or  Soft  Gold  Foil. — This  is  a  preparation  of  leaf  gold 
which  does  not  possess  the  property  of  cohesion  to  such  a  degree  that 
the  leaves  can  be  firmly  united  on  being  pressed  together  with  moderate 
force,  and  is  introduced  on  the  wedging  principle,  the  cavity  for  its  re- 
ception being  made  of  such  a  form  or  shape  as  will  retain  the  mass 
after  it  has  been  properly  introduced  and  consolidated. 

Non-cohesive  gold  foil  is  employed  in  different  forms,  such  as  the 
rope,  the  tape  or  ribbon,  the  cylinder,  the  pellet,  and  the  mat  or  block. 

The  thickness  of  the  leaves  is  determined  by  the  number  of  grains 
each  contains,  and  is  designated  by  numbers  on  the  books  between  the 
leaves  of  which  they  are  placed  after  having  been  properly  annealed. 
These  numbers  range  from  3  to  240.  A  book  containing  a  quarter  of 
an  ounce  of  No.  4  will  have  thirty  leaves  in  it.  Some  dentists  use 
foil  varying  in  numbers  from  4  up  to  20,  and  even,  of  late,  to  120,  while 
others  confine  themselves  to  a  single  number.  If  but  one  nunnber  of 
the  non-cohesive  be  used,  5  will,  perhaps,  be  found  better  than  any 
other.  The  author  has  used  Nos.  4,  5,  6,  8,  10  and  15,  but  he  prefers 
4. and  5,  and  is  decidedly  of  opinion  that,  in  a  large  majority  of  cases, 
a  better  filling  can  be  made  with  the  two  first  numbers  than  any 
of  the  others.  There  may  be  cases  in  which  higher  numbers  can  be 
more  advantageously  employed  ;  as,  for  instance,  in  cavities  which  are 
very  large,  and  where  the  operation  of  filling  has  extended  beyond  the 
walls  of  the  cavity,  owing  to  the  difficulty  of  securing  a  perfect 
adaptation. 

Cohesive   Gold   Foil. — This   is   a   preparation   of  leaf  gold    which 


TREATMENT   OF   DENTAL   CARIES.  431 

possesses  the  property  of  cohesion  to  such  a  degree  that  the  leaves 
readily  and  firmly  unite  on  being  pressed  together  with  moderate 
force. 

Although  one  or  two  others  claim  priority  in  the  discovery  of  the 
advantages  now  derived  from  the  use  of  cohesive  gold  foil,  yet  the 
credit  is  certainly  due  to  Dr.  Robert  Arthur,  as  he  was  not  only  the 
first  to  demonstrate  the  applicability  of  this  form  of  gold  in  filling 
teeth,  but  in  a  series  of  well  written  articles*  he  overcame  the  objec- 
tions which  were  at  first  urged  against  it,  and  proved  that  its  great 
cohesive  jDroperty  rendered  it  a  valuable  adjunct  in  the  preservation  of 
the  teeth.  This  form  of  foil  is  so  cohesive  that  any  number  of  pieces 
may  be  welded  one  to  another  ;  thus  a  part,  or  even  the  whole  of  the 
crown  of  a  tooth  may  be  built  up  wuth  it.  The  same  property  may  to 
a  limited  extent,  also  be  imparted  to  foil  manufactured  in  the  ordinary 
way,  by  re-annealing.  This  property  is  peculiarly  valuable  in  many 
cases  where  it  becomes  necessary  to  build  up  a  large  portion  of  the 
crown  of  a  tooth  ;  but  Avhen  it  is  used,  instruments  having  serrated 
points  are  required,  like  those  employed  in  the  use  of  crystal  or  sponge 
gold. 

Crystal  or  Sponge  Gold  has  been  employed  by  dentists  for  filling 
teeth  for  a  number  of  years.  The  author  has  used  it  in  a  number  of 
cases  with  very  satisfactory  results.  Since  the  publication  of  the  fifth 
edition  of  this  work,  the  properties  of  crystal  or  sponge  gold  have  been 
more  thoroughly  and  extensively  tested,  and  the  result  has  fully  con- 
firmed the  favorable  opinion  entertained  by  us  with  regard  to  its  value. 
The  author  is  acquainted  with  several  of  the  most  skillful  operators 
in  the  United  States  who  have  used  it  almost  exclusively  in  their 
practice  for  several  years ;  and  has  seen  fillings  made  by  some  of  these 
gentlemen,  which,  for  beauty  and  solidity,  he  does  not  think  could  be 
surpassed.  This  form  of  gold  has  a  spongy  texture,  being  composed 
of  crystals,  and  widely  differs  from  foil  or  leaf  gold.  The  ci'ystals 
possess  the  property,  when  pressed  firmly  against  each  other,  of  weld- 
ing and  becoming  as  solid  and  almost  as  incapable  of  disintegration 
or  crumbling  as  a  piece  of  bullion  or  coin.  This  property  enables  a 
skillful  manipulator  to  supply  almost  any  loss  which  a  tooth  may  have 
sustained,  even  to  the  building  up  of  an  entire  crown.  Still,  it  will 
never  supersede  the  use  of  cohesive  and  non-cohesive  gold  foils,  as 
there  are  many  ca^es  in  which  leaf  gold  can  be  used  more  advantage- 
ously and  wdth  moi-e  facility.  Nor  will  the  employment  of  it,  in  the 
opinion  of  the  author,  ever  become  universal ;  for  the  reason  that  more 
care  and  skill  are  required  to  make  a  good  filling  with  it  than  with 
leaf  gold,  especially  when  the  cavit}"  in  the  tooth  is  difficult  of  access. 
*  A  Treatise  on  the  Use  of  Adhesive  Gold  Foil,  1857. 


432  DENTAL   SUEGERY. 

Filling  with  crystal  gold  is  more  tedious  than  the  same  operation  with 
ordinary  foil. 

Experiments  have  been  made  with  silver,  platinum,  and  aluminium  ; 
but  with  unsatisfactory  results.  They  are  less  malleable  than  gold, 
and  therefore  cannot  be  made  so  thin ;  at  the  same  time  they  have  not 
the  softness  of  tin  ;  hence  they  work  harshly  under  the  plugger.  An 
additional  objection  to  silver  is  its  liability  to  undergo  chemical  change, 
being  in  this  respect  greatly  inferior  to  pure  tin.  Platinum,  while  it 
possesses  indestructibility,  in  this  respect  being  even  superior  to  gold, 
is  deficient  in  other  properties  as  a  filling  material,  as  it  cannot  be 
welded  with  facility,  is  difficult  to  manipulate  in  the  form  of  foil,  on 
account  of  its  stiffness  and  harshness,  and  hence  cannot  be  adapted  and 
condensed  in  such  form  to  the  surface  of  a  cavity.  A  form  of  platinum 
known  as  platinum  sponge  has  been  employed  with  greater  facility  than 
j)latinum  in  leaf  form,  but  it  requires  skillful  manipulation,  and  its 
cohesive  property  is  readily  destroyed  by  the  slightest  degree  of  moist- 
ure. Platinum  has  also  been  used  in  the  form  of  foil  coated  with  a 
considerable  thickness  of  pure  gold,  and  it  is  claimed  that  by  such  a 
combination  a  denser  filling  can  be  made,  and  also  one  conforming  to  the 
color  of  the  tooth  in  which  it  is  placed.  The  peculiarity  of  aluminium, 
in  this  relation,  is  the  impossibility  of  welding  its  leaves  by  pressure ; 
even  under  the  gold  beater's  hammer  it  forms  loose  scales,  which  no 
annealing  can  make  adherent. 

Tin  Foil. — This,  when  chemically  pure  and  properly  prepared,  is 
less  objectionable  for  filling  teeth  than  most  of  the  articles  hereafter 
enumerated.  Under  favorable  circumstances,  if  skillfully  introduced, 
it  will  prevent  the  recurrence  of  caries.  The  greatest  objection,  per- 
haps, to  the  use  of  tin  foil  as  a  filling  material,  is  its  softness  and  con- 
sequent inability  to  withstand  the  friction  of  mastication  for  many 
years.  When  used  in  cavities  not  so  exposed  it  answers  a  good  pur- 
pose as  a  filling  material,  as  it  is  unalterable  by  reagents.  Being  an 
inferior  conductor  of  heat  it  is  tolerated  in  sensitive  teeth  in  cases 
where  a  better  conductor,  such  as  gold,  would  not  be.  It  is  also 
regarded  as  valuable  in  soft  teeth,  and  some  regard  it  as  possessing 
advantages  over  gold  for  fillings  in  such  teeth,  and  also  in  the  tempo- 
rary teeth,  being  easy  of  introduction,  and  in  accord  with  the  tooth 
structure.  On  account  of  the  qualities  referred  to,  tin  foil  is  sometimes 
employed  for  lining  cavities  to  be  filled  with  gold.  It  is  prepared  as 
a  filling  material  in  the  form  of  foil,  the  leaves  varying  in  thickness 
from  No.  4  to  No.  20.  The  numbers  from  4  to  10  are  mostly  used, 
and  it  is  manipulated  in  the  same  manner  as  non-cohesive  gold  foil. 

Lead  is  far  more  objectionable  than  tin,  as  it  is  more  easily  decom- 
posed by  the  secretions  of  the  mouth  ;  its  introduction  into  the  stomach 


TREATMENT   OF   DENTAL   CARIES.  433 

might  be  productive  of  serious  injury  to  the  general  health  of  the 
patient.     But,  happily,  this  article  is  now  seldom  if  ever  used. 

Amalgam,  formerly  known  by  the  name  of  mineral  cement,  or 
lithodeon,  is  usually  composed  of  about  equal  parts,  by  weight,  of  pure 
tin,  silver,  and  varying  proportions  of  zinc  and  platinum — the  zinc, 
about  one  to  three  per  cent.,  constituting  a  most  important  element  in 
controlling  shrinkage  and  preventing  oxidation.  The  gold  and  platinum 
are  not  especially  valuable,  and  when  used  in  an  amalgam,  from  one 
to  four  per  cent,  of  either  is  sufficient.  These  metals  are  melted  in  a 
crucible  and  poured  into  ingots,  which  are  then  cut  up  with  a  file  into 
filings.  These  filings  are  mixed,  after  the  cavity  in  the  tooth  is  pre- 
pared for  the  filling,  with  about  thirty-three  and  one-third  per  cent,  of 
distilled  mercury,  and  incorporated  to  the  consistency  of  a  thick  paste. 
The  mass  is  then  thoroughly  washed  with  alcohol,  to  which  is  added  a 
few  drops  of  a  strong  solution  of  chloride  of  zinc.  The  excess  of 
mercury  is  then  removed  by  twisting  the  mass  in  a  piece  of  chamois 
skin  or  strong  muslin.  It  is  also  recommended  to  press  the  mass  quite 
thin,  after  it  is  removed  from  the  chamois  skin,  with  a  strong  pair  of 
flat  pliers,  in  order  to  remove  still  more  of  the  mercury.  Caution 
should,  however,  be  used,  to  avoid  pressing  out  too  much  mercury.  The 
mass,  when  introduced,  should  be  about  the  consistency  of  ordinary 
putty.  The  cavity  should  be  prepared  with  as  much  care  as  for  a  gold 
filling,  and  moisture  prevented  from  coming  in  contact  with  it.  When 
the  cavity  approaches  near  to  the  pulp,  some  non-conducting  substance, 
as  Hill's  Stopping,  should  be  applied  between  the  amalgam  and  the 
bottom  of  the  cavity.  After  the  filling  has  become  sufficiently  hard, 
its  surface  should  be  carefully  finished  by  filing  and  burnishing. 

Fig.  236  represents  a  set  of  what  are  known  as  Arrington's  amalgam 
instruments. 

Amalgam  becomes  hard  by  the  crystallization  of  the  mass  and  the 
evaporation  of  the  mercury ;  hence,  without  a  well-prepared  form  is 
used,  and  great  care  exercised  in  its  amalgamation  and  introduction,  a 
filling  of  this  material  may  either  contract  or  become  porous ;  and 
when  the  latter  is  the  case,  the  oxidation  extends  to  the  tooth  structure, 
which  becomes,  as  a  consequence,  discolored. 

Amalgams,  unlike  the  plastic  gutta-percha  and  zinc  preparations, 
do  not  adhere  to  the  walls  of  the  tooth  cavity ;  hence,  in  their  use  it  is 
necessary  that  attention  should  be  paid  to  the  form  of  cavity  into  which 
they  are  to  be  introduced;  and  as  they  are  often  employed  for  filling 
cavities  of  a  shallow  form,  and  with  frail  walls,  under-cuts  and  dovetails 
are  required  for  the  retention  of  such  fillings.  From  the  tendency  of  the 
amalgams  of  mercury  to  assume  a  spheroidal  shape  and  separate  from 
the  margins  of  a  cavity,  sharp  angles  and  pits  are  objectionable.  The 
28 


434 


DENTAX,  SURGERY. 


addition  of  palladium  to  an  amalgam  may  prevent  such  shrinkage,  but 
adds  to  the  discoloration,  and  the  rapidity  of  its  setting  is  such  as  to 
evolve  a  sufficient  amount  of  gas  to  cause  an  explosion  with  emission 
of  light.  Such  an  accident  may  be  avoided  by  gradually  adding  the 
palladium  powder  to  the  compound,  and  using  very  small  pieces  for 
introduction,  and  their  rapid  insertion,  each  piece  being  well  com- 
pounded as  it  is  added  to  the  mass.  It  is  claimed  that  while  the  surface 
of  a  palladium  amalgam  changes  to  a  black  color,  it  does  not  stain  the 
tooth  structure,  and  that  it  is  the  most  durable  of  the  amalgams.  An 
excess  of  silver  will  also  cause  an  amalgam  to  blacken  and  stain  the 
tooth  structure. 

A  better  class  of  amalgams  has  been  recently  introduced,  which 
appears  to  change  bulk  to  a  less  degree,  and  to  preserve  their  light, 
silvery  color  much  better  than  the  older  forms ;  hence,  the   former 

Fig.  236. 


objections  to  this  filling  material  appear  to  have,  in  a  great  measure, 
been  overcome.  The  ease  with  which  amalgam  fillings  can  be  intro- 
duced, no  doubt  often  leads  to  carelessness  in  the  manipulation  of  this 
material,  but  it  should  be  remembered  that  to  obtain  the  best  results 
from  it,  the  cavity  in  which  it  is  placed  should  be  as  carefully  prepared 
as  for  a  gold  filling ;  and  also  that  perfect  dryness  is  essential  to  its 
adaptation  and  durability. 

There  exists  some  difference  of  opinion  concerning  the  necessity  for 
washing  amalgam,  prior  to  its  introduction,  with  alcohol  and  other 
fluids,  some  contending  that  by  so  doing  it  is  impossible  to  remove  all 
of  the  moisture  in  time  for  its  insertion.  Sufficient  mercury  should  be 
allowed  to  remain  in  the  mass  as  will  permit  of  its  being  manipulated 
without  crumbling,  and  when  it  is  inserted  over  a  sensitive  surface,  or 


TREATMENT    OF    DENTAL    CAEIES.  435 

in  proximity  to  the  pulp  of  a  tooth,  some  interveuing  substance,  such 
as  Hill's  Stopping,  or  oxyphosphate  of  zinc,  should  be  placed  between 
the  sensitive  surface  and  the  filling. 

It  is  claimed  that  continuous  pressure  with  the  burnisher  upon  the 
surface  of  an  amalgam  filling  during  its  setting,  will  prevent  its  ten- 
dency to  separate  from  the  walls  of  the  cavity,  and  insure  better  results 
from  its  use.  It  is  also  very  necessary  that  the  margins  of  amalgam 
fillings  should  be  well  defined,  as,  owing  to  its  brittle  nature,  thin, 
overhanging  portions  are  liable  to  break  away,  leaving  imperfections 
which  may  soon  prove  injurious  to  the  filling.  After  an  amalgam 
filling  has  become  hard  (and  during  this  hardening  process  the  patient 
should  be  warned  against  masticating  upon  it),  the  surface  should  be 
as  carefully  prepared  and  polished  as  that  of  a  gold  filling. 

The  objections,  therefore,  urged  against  amalgam  are,  that  it  oxidizes 
and  blackens ;  that  the  tooth  structure  with  which  it  remains  in  con- 
tact becomes  discolored  ;  that  it  contracts  in  hardening,  allowing  the 
secretions  to  make  their  way  around  the  filling.  Of  late  years  it  has 
been  urged  that  it  is  incompatible  with  tooth  structure,  and  that  the 
mercury  might  act  injuriously  on  the  system.  These  objections  are 
characteristic  of  most  of  the  amalgams  now  on  the  market,  although 
in  a  few  notable  exceptions  they  have  been  almost  entirely  overcome ; 
but  there  is  no  good  reason  why  amalgam  should  be  incompatible  with 
tooth  structure,  or  that  the  small  amount  of  mercury  imprisoned  in 
this  alloyed  mass  should  possibly  produce  any  mercurial  efiects.  There 
is  good  reason,  therefore,  for  believing  it  to  be,  in  these  respects,  per- 
fectly inert.  The  use  of  amalgam  is  contra-indicated,  in  all  teeth  which 
can  be  filled  with  gold ;  in  the  front  teeth,  on  account  of  its  color ;  and 
in  pulp  cavities,  on  account  of  the  difficulty  of  introduction  into  small 
canals.  Various  opinions  are  held  as  to  the  indications  for  the  use  of 
amalgam.  In  our  own  opinion  it  is  one  of  the  most  valuable  materials 
for  some  operations,  as,  for  instance,  in  cavities  so  difficult  of  access  as 
to  render  the  introduction  of  a  perfect  gold  filling  doubtful,  and  where 
the  operations  would  be  long,  tedious  and  difficult,  to  both  patient  and 
operator,  were  gold  used. 

Fig.  237  represents  a  number  of  amalgam  Carriers  and  Fillers. 

Of  these  instruments,  Nos.  1,  2,  and  3  are  constructed  with  fixed 
points,  covered  by  a  tube,  which  projects  to  form  a  cup  for  the 
amalgam,  and  recedes  so  that  the  points  work  through  as  Pluggers  to 
force  it  into  the  cavity;  No.  1  being  half  curve,  No.  2  double-end, 
giving  two  angles,  and  No  3  straight.  No.  4  has  a  fixed  tube  with 
spring  plunger,  to  force  in  the  amalgam.  The  Loadstone  Carrier 
and  Plugger,  No.  5,  is  a  double-end  instrument,  one  point  of  which 
is  so  prepared  as  to  attract  amalgam,  which  will  adhere  to  it  while 


436 


DENTAL  SURGERY. 


Fig.  237. 


being  conveyed  to  the  cav- 
ity in  the  tooth ;  the  reverse 
end  is  made  as  a  Filler. 

Fig.  238  represents  a 
Mercury  Holder  for  conve- 
nient preparation  of  amal- 
gam. 

Fig.  239  represents  a 
set  of  Weston's  Amalgam 
Pluggers. 

Bobinson's  Textile  Metal- 
lic Filling  has  been  in  use 
for  several  years,  and,  on 
account  of  its  containing 
no  mercury,  has,  with  some 
practitioners,  taken  the 
place  of  amalgam  in  a 
large  per  cent,  of  cases. 
It  is  not  advisable  to  intro- 
duce it  in  very  large  pieces, 
as  they  cannot  be  manipu- 
lated with  accuracy,  and 
a  filling  of  this  material 
should  be  commenced  with 
a  cylinder  or  mass,  and  the 
remaining  portion  packed 
in  the  form  of  strips.     It 

Fig.  238. 


is  necessary  that  it  should 
be  thoroughly  malleted 
throughout  the  whole  pro- 


TREATMENT   OF   DENTAL   CARIES. 
Fig.  239. 


437 


•  fe. 


cess  of  filling,  as  otherwise  it  may  disintegrate  under  masti- 
cation. When  it  is  combined  with  gold,  and  both  metals  are 
exposed  to  the  fluids  of  the  mouth,  the  textile  filling  will 
become  black,  which,  however,  is  said  to  occur  on  the  exposed 
surface  only,  and  not  inside  the  tooth. 

Gutta-percha  and  Hill's  Stopping. — Gutta-percha  is  an  ex- 
cellent material  for  temporary  fillings.  It  may  be  made 
IJIIII  harder,  whiter,  and  less  contractile  by  incorporating  with  it 
some  very  fine  powder  of  feldspar,  silex,  lime,  or  magnesia. 
A  very  excellent  preparation  known  as  Hill's  Stopping  is  made 
by  mixing  gutta-percha  with  as  much  of  the  following 
powder  as  it  will  hold  without  becoming  brittle ;  quicklime, 
two  parts,  very  fine  quartz  and  feldspar,  one  part  each.  Of 
all  temporary  fillings  this  is  probably  the  best  yet  known. 
Prepared  gutta-percha  and  Hill's  Stopping  are  introduced 
in  small  pieces  by  first  warming  on  a  porcelain  or  metal  slab, 
over  an  alcohol  lamp,  until  they  become  plastic  enough  to 
be  readily  pressed  into  the  cavity  and  to  adhere  to  its  walls. 
As  soon  as  the  cavity  is  filled,  an  instrument  having  a  con- 
densing point  large  enough  to  cover  the  entire  surface  of  the  " 
filling  should  be  applied  and  kept  in  position  until  the  mass 
has  become  cool. 

Fig.  240  represents  a  cup  for  heating  gutta-percha  fillings, 
devised  by  Dr.  Flagg.  It  is  made  of  brass,  silver  or  nickel- 
plated,  to  be  filled  with  water  and  warmed  over  a  spirit-lamp. 
The  pellets  are  placed  upon  the  top  of  the  heated  cover,  from 
which  they  are  taken  up  when  introducing  them  into  the 
cavity.  The  surface  of  the  filling  is  then  cut  down  and 
burnished,  after  which  a  little  chloroform  may  be  applied,  by  means 
of  a  camel's-hair  brush,  to  complete  the  finishing  process. 

The  preparations   of  gutta-percha   now  used  for  filling  materials 


438 


DENTAL   SURGERY. 


Fig.  240. 


possess  different  grades  of  plasticity,  so  that  a  filling  may  be  com- 
menced with  one  that  softens  at  a  low  temperature,  and  finished  with 
another  which  requires  more  heat- to  render  it  plastic,  and  hence  be- 
comes harder.    For  cavities  situated  on  the  approximal  surfaces  of  the 

teeth  and  extending  below 
the  margin  of  the  gum, 
gutta-percha  preparations 
appear  to  answer,  a  good 
purpose  in  resisting  the  dis- 
solving action  of  the  acid 
from  the  inflamed  gum. 
When  the  gutta-percha 
preparation  is  made  plastic 
enough  to  adhere  to  the 
walls  of  a  cavity,  by  passing 
it  through  the  flame  of  a 
spirit-lamp,  care  is  required 
that  it  should  be  evenly 
heated  and  not  burut.  By 
using  the  lower  grade  over 
sensitive  portions  of  a  cav- 
ity, less  pain  is  experienced  from  the  heat,  and  after  the  cavity  is  filled 
with  the  higher-grade  material,  the  surplus  can  be  removed  with  thin 
steel  or  platinum  spatulas  heated  to  the  required  degree,  and  the 
surfaces  made  smooth  by  passing  over  it  a  burnisher.  Chloroform 
applied  to  the  surface  of  a  gutta-percha  filling  will  give  a  smooth 
finish,  but  may  render  such  a  surface  less  durable,  on  account  of  its 
dissolving  action. 

Fig.  241. 

0 


Fig.  241  represents  a  set  of  Dr.  W.  A.  Bronson's  gutta-percha 
instruments. 

Zinc  Preparations. — A  mixture  of  chloride  of  zinc  and  oxide  of 
zinc  has  been  much  used  under  the  various  names  of  oxychloride  of 


TREATMENT   OF   DENTAL   CARIES.  439 

zinc,  OS-art ificiel,  osteo-dentine,  osteo-plast{c,mmeTal  paste,  etc.  Quackery 
has  seized  it  with  eagerness,  and  plastered  up  many  teeth  with  a  mortar 
even  more  conveniently  used  than  amalgam.  Although  in  some  few 
cases  it  may  resist  the  action  of  the  secretions  of  the  mouth,  it  will  not 
answer  for  a  permanent  filling.  The  friction  of  mastication  soon  destroys 
it,  and  in  approximal  cavities  it  frequently  crumbles  away  in  a  few  weeks 
or  months.  Still,  as  a  temporary  filling,  it  may,  if  employed  with  caution 
and  judgment,  be  found  useful,  and  for  certain  cases  very  valuable. 
It  has  been  used  with  success  for  filling  the  pulp  cavities  of  the  teelh. 
It  has  also  been  applied  to  exposed  nerves,  and  in  some  favorable  cases 
successfully ;  but  its  use  for  such  a  purpose  is  very  uncertain,  as  the 
escharotic  action  of  the  zinc  chloride  will  almost  certainly  produce 
death  of  the  pulp.  In  the  combination  of  the  oxychloride  ingredients 
the  oxide  of  zinc  is  usually  mixed  with  some  silicious  substance,  to 
increase  the  hardness,  and  the  chloride  of  zinc  is  diluted  with  water. 
When  the  powder  and  liquid  are  combined  a  cement  results,  which 
forms  hydrated  oxychloride  of  zinc,  by  the  taking  up  of  some  of  the 
water  as  a  base.  Some  prefer  mixing  the  oxychloride  in  the  form  of 
a  thin  paste,  and  after  adapting  it  carefully  to  the  bottom  and  sides  of 
the  cavity,  or  over  a  sensitive  surface,  to  complete  the  operation  with 
a  paste  of  thicker  consistency.  A  warm  burnisher  will  hasten  the 
setting  of  the  oxychloride,  and  apparently  increase  its  hardness.  The 
application  of  talc  (soapstone),  in  the  form  of  a  properly-shaped  point, 
which  may  be  heated,  or  in  the  form  of  powder,  appears  to  improve 
the  surface  of  such  a  filling,  by  rendering  it  less  permeable  to  moisture. 
On  account  of  the  oxychloride  preparation  being  acted  on  by  weak 
acid  and  even  alkaline  solutions,  it  cannot  be  depended  upon  for  a 
permanent  filling  material,  and  will  frequently  dissolve  away  in  a  few 
weeks  or  months,  especially  if  introduced  near  to  or  beneath  the 
margin  of  the  gum.  It  often  answers  a  good  purpose  when  applied  to 
sensitive  dentine,  but,  like  the  chloride  of  zinc,  one  of  its  ingredients, 
its  application  causes  considerable  pain  for  a  short  time.  It  has  also 
been  employed  for  bleaching  discolored  dentine,  and  as  an  interposing 
substance  between  a  thin  wall  of  cavity  and  darker  but  more  durable 
filling  material,  such  as  amalgam. 

Of  late  years,  various  preparations,  known  as  oxyphosphates  of  zinc, 
have  been  introduced,  composed  of  the  basic  oxide  of  zinc  and  glacial 
phosphoric  acid.  One  of  these  preparations  is  said  to  be  composed  of 
the  nitrate  of  zinc  and  phosphoric  acid.  The  oxyphosphate  prepara- 
tions are  preferable  to  the  oxychlorides,  on  account  of  their  being  less 
irritant  to  the  pulp  and  more  durable,  especially  when  placed  about 
the  necks  of  the  teeth.  They  have  also  the  advantage  over  the  oxy- 
chlorides of  greater  hardness ;  but  it  should  be  remembered  that  all 


440  DENTAL  SURGERY. 

of  the  zinc  preparations  are  liable  to  be  dissolved  by  the  fluids  of  the 
mouth,  and  hence  are  not  so  reliable  for  temporary  fillings  as  gutta 
percha,  especially  the  form  known  as  Hills'  Stopping,  particularly 
where  such  fillings  extend  beneath  the  margin  of  the  gum  to  the 
cementum. 

The  oxyphosphates  mix  less  readily  than  the  oxychlorides,  and  require 
more  care  in  the  combination  of  the  powder  and  liquid.  If  mixed  too 
thin,  a  sticky,  unmanageable  mass  results,  and  if  too  thick  the  mass 
will  crumble  in  pieces ;  it  is  therefore  recommended  to  so  prepare  it 
that  it  may  be  rolled  between  the  thumb  and  finger  without  adhering 
to  them,  or,  on  the  other  hand,  crumbling  to  pieces.  On  account  of 
the  oxyphosphate  setting  very  rapidly,  the  cavity  should  be  ready  to 
receive  it  before  it  is  mixed,  by  being  free  and  protected  from  moisture 
by  the  application  of  the  rubber-dam.  Like  the  oxychloride,  it  is 
necessary  that  the  surface  of  a  filling  of  this  material  should  be  pro- 
tected from  moisture  for  some  minutes  after  its  introduction,  and  the 
same  substance  may  be  used  to  coat  over  the  surface,  as  in  the  case  of 
the  oxychloride.  Unlike  the  oxychloride,  however,  a  warm  instru- 
ment cannot  be  employed  to  hasten  its  setting.  A  number  of  forms 
of  these  cements  are  in  use  under  the  names  of  those  originating  them. 
One  form,  known  as  Poulson's,  is  the  pyrophosphate  of  zinc,  the  pyro- 
phosphoric  acid  being  in  crystals,  which  require  to  be  melted  in  a 
platinum  or  porcelain  spoon,  held  over  a  spirit  lamp,  care  being  taken 
that  ebullition  does  not  occur.  When  reduced  by  heat  to  the  con- 
sistency of  glycerine,  it  is  dropped  upon  a  warm  porcelain  slab,  and  is 
ready  for  introduction  into  the  cavity.  Exposure  of  this  preparation 
to  the  air  causes  its  deterioration,  hence  it  should  be  kept  in  hermeti- 
cally sealed  vessels.  Some  of  these  plastic  zinc  preparations  appear  to 
be  much  less  soluble  in  some  mouths  than  in  others,  and  considerable 
importance  is  attached  to  the  manner  in  which  they  are  mixed  and 
inserted  into  the  cavity. 

In  using  any  of  these  preparations,  the  cavity  is  prepared  as  usual ; 
then  a  small  quantity  of  the  liquid  (either  the  chloride  of  zinc  or  the 
phosphoric  acid)  is  dropped  upon  a  piece  of  glass  or  porcelain,  and 
enough  of  the  powder  (oxide  of  zinc)  added  to  make  a  paste  so  thick 
that  the  surface  will  not  appear  watery.  The  cavity  is  then  perfectly 
dried  and  protected  from  saliva  and  the  material  quickly  introduced, 
after  which  it  is  kept  free  from  moisture  for  ten  or  twenty  minutes. 
When  sufficiently  hard,  the  surface  is  finished  by  scraping  and  polish- 
ing. The  longer  the  surface  is  kept  dry,  the  harder  these  materials 
become.  Coating  the  surface  with  sandarach  varnish  (or  gutta-percha 
dissolved  in  chloroform,  or  melted  wax)  will  afford  protection  for  some 
time. 


TREATMENT   OF   DENTAL   CARIES. 


441 


Fig.  242. 


In  all  cases  where  these  prepara- 
tions are  introduced  near  a  pulp,  or 
as  a  capping  over  exposed  pulps, 
the  cavity  should  always  be  previ- 
ously wiped  out  with  a  solution  of 
gutta-percha  and  chloroform,  to 
prevent  the  escharotic  and  irritant 
effect. 

Fig.  242  represents  platinum 
points  for  oxychloride  and  oxy- 
phosphate  fillings. 

Fig.  243  represents  the  Agate 
Burnisher,  which  is  considered  to 
be  superior  to  any  other  burnisher 
for  surface  finishing  of  oxychloride 
and  oxyphosphate  fillings. 

Fig.  243. 


Fig.  244. 


f     \l 


442 


DENTAL   SURGERY. 


Fig.  245. 


Fig.  246. 


Fig.  244  represents  the  points  of  different 
forms  of  spatulas  for  mixing  the  zinc  prepara- 
tions, which  is  conveniently  done  on  a  porcelain 
pallette,  such  as  is  used  by  artists. 

Fig.  245  represents  a  common  form  of  mouth 
mirror,  of  which  both  plain  and  magnifying  are 
used  in  examining  the  teeth.  Dr.  Maynard,  of 
Washington,  has  recently  made  an  improve- 
ment in  mouth  mirrors  by  substituting  pebbles 
for  glass,  which  more  clearly  reflect  the  objects 
they  picture. 

Fig.  246  represents  Reflectors  for  attachment 
to  rubber-dam  clamps,  so  that  while  providing 
a  strong  light,  both  hands  of  the  operator  are 
left  free  for  manipulation.  They  are  useful  in 
operations  upon  posterior  cavities  in  molars. 
By  means  of  a  ball-joint  the  mirror  can  be  ad- 
justed to  concentrate  the  light  upon  the  cavity 
or  any  portion  of  the  mouth  required. 

Instruments  known  as  Stomatoscopes  have 
been  devised  for  the  purpose  of  obtaining  a 
perfect  light  for  operations  on  the  distal  sur- 
faces of  molars  and  bicuspids,  and  are  found  to 
be  especially  useful  when  the  sky  is  cloudy,  and 
for  night  work.  Such  instruments  as  the 
Grohnwald  and  Beseler  Stomatoscopes,  which 
are  capable  of  being  so  adjusted  as  to  throw 
light  to  any  part  of  the  mouth  necessary  in  fill- 
ing teeth  may  be  used.  Dr.  C.  F.  W.  Bodecker 
asserts  that  by  aid  of  a  Stomatoscopje  he  was  en- 
abled to  see  up  to  near  the  apex  of  the  pulp  canal 
of  a  palatal  root  of  a  first  upper  molar,  the  cavity 
being  on  the  distal  and  grinding  surface. 

The  electric  light  has  also  been  utilized  for 
the  same  purpose,  and  also  for  examinations  of 
the  throat,  and  even  of  the  stomach.  Mr.  E.  T. 
Starr,  of  the  S.  S.  White  dental  establishment. 


TREATJSrENT    OF    DENTAL    CARIES.  443 

has  quite  recently  succeeded  in  obtaining  highly  satisfactory  results  in 
this  direction.  His  instrument  consists  of  a  lamp  formed  of  a  delicate 
glass  bulb,  from  which  the  air  has  been  withdrawn  and  as  nearly 
a  perfect  vacuum  created  as  possible.  The  bulb  varies  in  shape, 
being  spheroidal,  flat  and  compass-shaped,  and  also  cylindrical,  with 
a  conical  termination.  Through  the  thin  walls  of  the  lamp  run  the 
conducting  Avires,  connected  by  a  carbon  arc,  on  which  the  electric- 
ity centres,  and  which  thus  becomes  the  place  of  light.  The 
glass  lamp  is  very  small,  the  cylindrical-shaped  being  scarcely 
half  an  inch  in  length,  and  with  a  diameter  much  less  than  that  of 
an  ordinary  lead  pencil.  The  compass-shaped  lamp  is  about  one- 
quarter  of  an  inch  thick,  and  has  a  diameter  of  three-quarters  of 
an  inch  to  an  inch,  while  the  spheroidal  is  scarcely  larger  than  a 
good-sized  pea.  The  lamp  is  attached  to  a  handle  from  seven  to 
nine  inches  long,  and  about  half  an  inch  thick,  through  which  run 
the  wires  connecting  with  the  battery.  The  intensity  of  the  power  and 
the  brilliancy  of  the  arc  of  light  can  be  regulated  by  moving  along 
the  handle  a  ring  which  connects  with  the  wires.  The  handle  has 
several  joints,  and  its  position  can  be  arranged  so  as  to  adapt  it  to  the 
shape  of  the  cavity  it  is  to  illuminate.  Mirrors  can  also  be  fastened  to 
the  lamp,  and  light  reflected  to  places  where  the  lamp  cannot  be  in- 
troduced. To  prevent  the  too  great  radiation  of  heat  and  the  difl'usion 
of  light,  the  lamp  may  be  partially  covered  with  a  hard  rubber  or  gutta- 
percha case.  When  the  lamp  is  placed  in  the  mouth  of  a  patient,  every 
portion  of  the  throat,  even  to  the  lowest  parts,  and  every  recess  of  the 
upper  places,  can  be  plainly  seen.  Placed  behind  the  teeth,  the  in- 
tense light  renders  not  only  the  teeth,  but  even  the  gums  above,  highly 
transparent.  If  the  teeth  are  good  and  free  from  caries,  no  lines  will 
be  visible,  but  the  presence  of  a  filling,  or  the  beginning  of  caries  may 
at  once  be  seen.  When  the  lamp  is  placed  Avithin  the  mouth,  and  the 
lips  are  closed,  the  entire  front  structure  of  the  mouth  is  brought  to 
view.  No  unpleasant  sensations  are  experienced,  even  in  cases  of  pro- 
tracted use. 

Fig.  247  represents  the  "  Electric  Mouth  Lamp,"  or  "  Stomatoscope." 
The  Electric  Mouth  Lamp  will  be  found  an  invaluable  assistant  to 
the  dentist  in  diagnosing  lesions  of  the  teeth  and  associate  parts  espe- 
cially in  those  obscure  cases  where,  although  there  are  unmistakable 
symptoms  of  serious  pathological  disturbance,  careful  examination 
with  the  appliances  heretofore  in  vogue  fails  to  discover  the  exact 
location  of  the  trouble.  Sound  teeth  are  sometimes  needlessly  sacri- 
ficed in  fruitless  endeavors  to  find  the  seat  of  neuralgic  pains  for 
which,  owing  to  the  insufficiency  of  the  means  of  diagnosis,  no  satis- 
factory cause  can  be  established.     The  Electric  Mouth  Lamp  illumi- 


444 


DENTAL   SURGERY. 


Fig.  247. 


nates  the  oral  cavity  so 
brilliantly  that  any  de- 
parture from  normality, 
whether  it  be  a  hidden 
cavity  of  decay,  an  un- 
suspected dead  pulp,  or 
even  the  slight  thicken- 
ing of  the  tissues  which 
is  theprecursor  of  decay, 
is  unerringly  detected. 

This  apparatus  will 
also  be  found  very  use- 
ful in  the  operating 
room  in  other  directions. 
In  the  preparation  of 
inaccessible  cavities  it  is 
often  difficult  to  tell 
when  the  excavation  has 
proceeded  far  enough, 
but  the  Electric  Mouth 
Lamp  will  show  at  once 
whether  all  the  disinte- 
grated tooth  substance 
has  been  removed. 

Besides  its  uses  in 
dentistry,  this  lamp  will 
find  extended  applica- 
tion in  general  medicine 
and  surgery,  as  an  illu- 
minating speculum  for 
the  examination  of  in- 
terior cavities  of  the 
body. 

In  use  the  lamp  is 
placed  behind  the  ob- 
ject to  be  illuminated — 
that  is,  so  that  the  object 
is  interposed  between 
the  lamp  and  the  eye  of 
the  observer.  Thus,  in 
examining  the  teeth  the 
lamp  is  placed  within 
the    arch,   so    that    its 


TREATMENT    OF    DENTAL   CARIES. 


445 


light  falls  upon  the  lingual  or  palatal  surfaces  of  the  teeth,  while  the 
eye  of  the  operator  is  directed  to  the  labial  or  buccal  surfaces.  So 
lighted,  every  portion  of  the  teeth  and  gums  is  thrown  into  strong 
relief;  the  sound  teeth  will  appear  translucent  and  with  no  varia- 
tions in  texture,  but  a  dead  tooth  will  be  at  once  detected  by  its 
opaque  or  dark  appearance,  even  although  to  ordinary  observation 
its  color  would  indicate  vitality.  A  cavity  of  decay,  or  any  foreign 
substance  about  the  teeth  will  show  as  plainly  as  a  spot  upon  a  window- 
pane.  A  healthy  root  will  not  be  distinguishable  from  the  membrane 
surrounding  it ;  but  caries  of  the  pulp  canal  or  any  thickening  of  the 
tissues  will  be  brought  out  by  the  illumination. 

For  the  examination  of  posterior  cavities  in  teeth,  a  mirror  is 
attached  to  the  guard  in  front  of  the  lamp  globe,  forming  a  perfect 
apparatus  for  the  purpose. 

It  has  been  found  impossible,  so  far,  to  make  the  lamps  of  exactly 
equal  power,  but  the  variation  is  not  great.  To  develop  their  full 
capacity  requires  about  3i  to  4J  volts — say  the  current  from  two  to 
three  cells  of  a  Bunsen  battery.  The  cells  of  the  battery  supplied 
with  the  Electro-magnetic  Mallet  are  excellent  for  the  purpose,  or 
three  or  four  cells  of  any  bichromate  battery  will  answer. 

The  circuit  should  be  broken  occasionally  during  a  prolonged 
examination,  and  also  whenever  the  lamp  is  not  in  use,  to  prevent 
its  becoming  so  hot  as  to  be  unbearable  in  the  mouth. 

For  the  examination  of  posterior  cavities  a  mirror,  set  at  an  angle 
of  45  degrees,  is  attached  to  the  end  of  the  guard.  With  the  mirror 
attachment  the  Electric  Mouth  Lamp  forms  a  perfect  laryngoscope. 

Instruments  for  Forming  the  Cavity. — Fig.  248  represents  a 
set  of  instruments  called  "  Explorers,"  useful  for  examining  the  teeth 


Fig.  248. 


((\\ 


to  determine  the  presence  of  caries.  For  the  removal  of  the  diseased 
part  of  the  tooth,  and  the  formation  of  a  cavity  for  the  proper  recep- 
tion and  retention  of  a  filling,  a  variety  of  instruments  are  required, 
which  should  be  constructed  of  the  best  steel,  and  so  tempered  as  to 


446 


DENTAL,  SURGEKY. 


prevent  tbem  from  either  breaking  or  bending.  Their  points  should 
be  so  shaped  that  they  may  be  conveniently  applied  to  any  part  of  a 
tooth,  and  made  to  act  readily  upon  the  portion  which  it  is  necessary 
to  remove. 

The  instruments   employed  for  this  purpose   are   excavators  and 
chisels.     Fig  249  represents  some  of  the  many  forms  of  excavators  in 


Fig.  249. 


<^ 


^ 


0  [I    n  ^  I 


1  If   If  \  if  ^f 


TREATMENT   OF   DENTAL   CARIES. 


447 


use,  and  Fig.  267,  page  455,  the  various  forms  of  chisels.  They  may 
be  formed  either  with  handle  and  point  in  one  piece  or  fitted  to  sepa- 
rate handles  made  of  wood,  ivory,  pearl  or  cameo ;  or  be  made  to  fit 
into  one  common  socket  handle.  The  recent  introduction  of  cone- 
socket  handles  has  supplanted  all  other  styles  of  socket-handle  in- 
struments. These  handles  are  made  of  steel,  nicely  engraved  and 
nickel-plated.     Fig.  250  represents  such  instruments. 

Fig.  250. 


Fig.  251  represents  the  form 
of  plyers  for  screwing  the  points 
into  the  cone-socket  handles. 

Fig.  252  represents  Dr.  W.  C. 
Head's  approximal  surface  exca- 
vators,  intended  chiefly  for  use 


Fig.  251. 


Fig.  252. 


in  preparing  cavities  between  Fig.  253. 

the  upper  front  teeth,  work- 
ing from  underneath,  but  are 
also  useful  on  bicuspids  where 
compound  cavities  are  to  be 
formed  for  contour  fillings. 

The  flat  and  burr-headed 
drills  represented  in  Fig.  253 
are  very  useful  for  enlarging 
the  orifice  of  a  cavity.  When 
hand  instruments  of  this  class 
are  used,  the  pressure  of  the 
instrument  against  the  hand,  between   the   thumb   and  forefinger  is 


448 


DENTAL  SURGERY. 


often  productive  of  much  irritation,  to  prevent  which  a  socket-ring 
or  shield,  like  those  represented  in  Fig.  254,  may  be  used  with  ad- 
vantage. It  consists  of  a  ring  adapted  for  the  fore  or  middle  finger, 
with  a  small  socket  attached  to  the  inside. 

Fig.  254. 


The  use  of  excavating  burrs,  by  means  of  the  dental  engine,  has 
almost  supplanted  the  separate  handle  drills.  Fig.  255  represents  a 
variety  of  forms  of  excavating  burrs  and  drills  for  use  with  the  dental 
engrine. 


Fig.  255. 


i 


C^      ffig       BSS         ^SP 


H     II 


EorsD. 


Wheel. 


Cone, 


IXVEETED   COJJE. 


TREATMENT   OF   DENTAL   CARIES. 


449 


Fig.  255  (Continued). 


Fissure,  Square  End. 


II    11    I 


Fissure,  Pointed. 


Oval. 


Spade. 


^ 


Five-sided. 
29 


1 


i.i  ii  ii  1 


ImIip  m  mill 
Square. 


Flat,  Square  Point. 


'I 
111 

KOUND. 

It 


I 

i 


"Flexible"  Burrs  and  Drills. 


450 


DENTAL   SURGERY. 

Fig.  256. 


.  S.  White  Dental  Engine. 


TREATMENT   OF   DENTAL   CARIES. 
Fig.  257, 


451 


Johnston  Dental  Engine. 


Figs.  256  and  257  represent  the  S.  S.  White  and  Johnston  styles 
of  dental  engines,  a  valuable  invention,  for  which  the  profession  is 
indebted  to  Dr.  Morrison,  of  St.  Louis,  and  by  means  of  which  instru- 
ments, such  as  burrs,  drills,  disks,  condensing  points,  burnishers,  wood- 
points,  etc.,  are  effectively  employed. 

Fig.  258  represents  the  S.  S.  White  water-motor  dental  engine, 
which  can  be  run  with  from  fifteen  to  twenty  pounds  pressure,  and 


452 


DENTAL  SURGERY. 

Fig.  258. 


,1  ur  "    ."i^'i 


TREATMENT   OP   DENTAL   CARIES. 


453 


will  make  over  3000  revolutions  per  minute.  The  cable  of  an 
S.  S.  White  engine  can  be  attached  to  a  Backus,  Tuerck  or  other 
water-motor,  which  will  make  an  efficient  motive  power. 

Fig.  259  represents  the  Bonwill  Dental  Engine  and  Hand  Piece. 


Fig.  259. 


Bonwill  Dental  Engine. 


454 


DENTAL,   SUEGEEY. 


Fig.  260  represents  Dr.  A.  M.  Holmes'  device  for  the  convenient 
oiling  of  the  engine  bits,  and  its  use  will  also  keep  the  hand-piece  in 
good  condition. 

Fig.  261  represents  a  revolving  stand  for  engine  bits,  disks,  etc. 

Fig.  262  represents  a  Rubber  Bulb  Chip  Syringe,  for  blowing  the 
cuttings  and  dust  from  cavities  by  means  of  cold  air. 


Fig.  260. 


Fig.  261. 


Fig.  262.     Fig.  263. 


Fig.  263  represents  an  elastic  bulb  syringe  for  cleansing  cavities. 
The  bulb  is  first  compressed,  and  the  point  is  then  inserted  under 
water,  when  it  fills  itself. 

A  three-sided  instrument  brought  to  a  point  (Fig.  264),  as  also  a 
chisel-edged  (Fig.   265),  and  a  four-sided  one  with   a  cutting  edge 

Fig.  264. 


Fig.  265. 


Fig.  266. 


(Fig.  266),  may  often  be  used  advantageously  in  cutting  away  por- 
tions of  enamel  to  enlarge  the  orifice.  These  instruments  are  now 
almost  entirely  superseded  by  the  use  of  the  variously-shaped  burrs  and 
drills,  to  be  used  with  the  dental  engine  (Fig.  255).  Enamel  chisels  of 
other  shapes,  and  gouges,  are  also  very  valuable  instruments  for  the 
preliminary  operation  of  opening  large  cavities,  or  cutting  ofi"  sound 
enamel  or  dentine  whenever  necessary. 

But  the  cavity  can  seldom  be  completed  with  either  of  the  instru- 
ments mentioned   above.     After  it  has  been  opened,  and  the  orifice 


TREATMENT   OF   DENTAL   CARIES.  455 

made  sufficiently  large,  it  should  be  finished  with  excavators  (Fig. 
249)  and  burrs  (Fig.  255),  properly  adapted  to  the  purpose ;  in  fact, 
in  the  majority  of  cases  it  should  be  wholly  formed  with  instruments 
of  this  sort. 

Excavators,  shaped  like  those  represented  in 
Fig,  249,  have  been  found  by  the  author  to  be  Fig.  267. 

as  well  adapted  to  the  removal  of  caries  as  any 
which  he  has  ever  employed.  There  should  be 
several  sizes  of  each  shape ;  also  duplicates  of 
each  instrument,  to  prevent  delay  in  case  of  acci- 
dent while  operating.  As  the  proper  formation 
of  the  cavity  greatly  depends  on  having  suitable 
instruments,  every  operator  should  be  provided 
with  a  large  supply  of  burr  drills  and  excavators, 
so  that  he  may  never  be  at  a  loss  for  such  as  the 
peculiarity  of  any  case  may  require.  He  should  also  have  the  mate- 
rial, and  know  how,  in  an  emergency,  to  point  his  own  excavators. 
For  this  purpose  he  will  need  a  lamp,  a  small  anvil  and  hammer,  a  set 
of  fine-cut  files,  such  as  are  used  by  watchmakers,  and  an  assortment 
of  steel  rods  of  various  sizes  and  of  the  best  quality.  It  is  not  our 
purpose  to  give  specific  directions  for  working  steel ;  but  Ave  would  oflfer 
two  cautions  :  first,  small  points  quickly  become  brittle  by  hammering, 
and  need  frequent  annealing  ;  second,  steel  is  greatly  injured  by  raising 
it  to  a  full  red  or  white  heat.  A  very  fine  temper  may  be  given,  after 
shaping  the  point,  by  heating  to  redness  and  suddenly  plunging  it  in 
wax  or  tallow. 

As  excavators  must  be  kept  very  sharp,  an  oil-stone  should  be  con- 
stantly at  hand.  The  Arkansas,  Hindostan  or  Superior  stones  are 
superior,  for  this  purpose,  to  all  other  varieties,  on  account  of  their 
hardness,  fineness,  and  sharpness  of  grit. 

Manner  of  Forming  the  Cavity. — The  preparation  of  the  cavity  in  a 
tooth  for  the  reception  of  a  filling,  is  a  very  essential  part  of  the  opera- 
tion, and  though  usually  the  easiest,  is  sometimes  attended  with  much 
difficulty.  The  removal  of  the  diseased  part  is  sometimes  all  that  is 
necessary,  preparatory  to  the  introduction  of  the  gold  ;  but  in  the  ma- 
jority of  cases  the  cavity  must  be  so  shaped,  as,  when  properly  filled, 
to  retain  the  filling  in  place. 

Where  the  orifice  to  a  cavity  is  small  and  contracted,  it  should  be 
enlarged,  by  means  of  a  burr  drill,  sufficiently  to  allow  the  use  of  exca- 
vators to  remove  the  softened  dentine.  Small  cavities  may  not  only 
be  enlarged,  but  cleaned  and  formed,  by  the  drills. 

Some  prefer  excavators  in  the  form  of  scoops,  for  the  removal  of  the 
softened  dentine,  which  should  be  completely  removed,  and  a  dense. 


456  DENTAL  SURGERY. 

normal  surface  reached,  due  regard  being  had  to  avoid  injury  to  the 
pulp  of  the  tooth.  A  knowledge  of  the  anatomical  structure  of  the 
teeth  will  enable  the  operator  to  avoid  penetrating  to  dangerous  points 
when  excavating  cavities.  Burrs  operated  by  the  dental  engine  can 
be  applied  at  almost  any  angle,  and  prove  very  serviceable  in  preparing 
cavities  for  fillings. 

The  part  of  the  tooth  surrounding  the  orifice  should  present  no 
rough  or  brittle  edges.  The  size  of  the  bottom  of  the  cavity  should  be 
as  near  that  of  the  orifice  as  is  possible,  even  a  little  larger,  rather  than 
anv  smaller.  But  the  difference  between  the  size  of  the  one  and  the 
other  should  never  be  very  great ;  for  if  the  interior  of  the  cavity  is 
much  larger  than  the  orifice,  it  will  be  difficult  to  make  the  filling 
sufficiently  firm  and  solid  to  render  it  absolutely  impermeable  to  the 
fluids  of  the  mouth.*  If,  on  the  other  hand,  the  orifice  is  larger  than 
the  bottom  of  the  cavity,  it  will  be  difficult  to  obtain  sufficient  stability 
for  the  filling,  so  as  to  prevent  it  from  ultimately  loosening  and  coming 
out.  It  often  happens,  however,  that  the  situation  and  extent  of  the 
decay  is  such  as  to  render  it  impossible  to  make  the  cavity  so  large 
at  the  bottom  as  at  the  orifice ;  when  this  is  the  case,  several  pits  or 
circular  grooves  should  be  cut  in  the  inner  walls,  for  the  purpose  of 
obtaining  as  much  security  for  the  filling  as  possible  ;  being  careful  to 
make  these  in  the  dentine  rather  than  in  the  enamel,  which  is  so  much 
more  brittle.  By  proper  attention  to  this  precaution,  a  filling  may 
be  so  inserted,  in  this  difficult  class  of  cases,  as  to  prevent  it  from 
coming  out. 

As  a  general  rule  it  is  easier  to  form  a  cavity  in  the  grinding  surface 
of  a  molar  or  bicuspid,  than  in  any  other  position  ;  though  it  some- 
times happens  that  even  here  it  is  attended  with  difficulty,  and  espe- 
cially when  the  decay,  commencing  in  the  centre,  follows  the  several 
depressions  which  run  out  from  it.  In  such  cases  the  edges  bordering 
on  and  covering  the  affected  parts,  which  are  often  thick  and  very 
hard,  should  be  cut  away,  together  with  the  subjacent  decayed  dentine ; 
the  radiating  depressions  should  open  fully  into  the  central  cavity,  and 
be  made  sufficiently  wide  and  deep  to  admit  of  being  filled  to  their  ex- 
tremities in  the  most  perfect  and  substantial  manner.     The  surface  of 

*  Place  a  lump  of  cotton  in  the  hollow  of  the  hand  formed  by  bringing  the 
ends  of  the  fingers  against  the  palm.  Then  press  with  an  instrument  upon  the 
centre  of  the  cotton,  and  it  will  leave  the  sides  of  the  cavity.  This  simple  illus 
tration,  suggested  by  Dr.  Edward  Maynard,  will  explain  the  cause  of  failure,  in 
certain  cases  which  have  come  under  his  notice,  from  the  hands  of  operators  of 
deservedly  high  reputation.  The  cavity,  smallest  at  the  orifice,  had  been  well 
filled;  but  the  final  compression  upon  the  centre  had  drawn  the  gold  from  the 
sides,  thus  permitting  the  access  of  fluids,  and  ultimately  decaying  the  tooth 
around  the  filling. 


TREATMENT   OF   DENTAL   CARIES.  457 

a  filling  occupying  a  cavity  of  this  kind  presents  a  sort  of  stellated  ap- 
pearance. When  two  or  more  decayed  places  are  separated  only  by 
very  thin  walls  of  tooth  substance,  these  should  be  cut  away,  and  a 
cavity  formed  large  enough  to  include  all  the  diseased  points  ;  as  one 
large  filling  will  secure  the  preservation  of  the  tooth  more  effectually 
than  by  filling  each  cavity  separately. 

Sharp  angles  should  be  avoided,  as  far  as  possible,  in  the  outTine  of 
the  orifice  of  the  cavity,  because  of  the  extreme  difficulty  of  filling  them 
compactly.  The  orifice  must  also  have  a  firm,  decided  margin,  with 
no  thin  projecting  edges  of  enamel  on  the  one  hand  ;  with  no  counter- 
sunk depressions  on  the  other.  In  the  first  case  the  thin  enamel  is  apt 
to  break  ofi"  either  during  the  operation  or  subsequently  ;  in  the  second 
case  the  thin  scale  on  the  edge  of  such  fillings  breaks  away  in  the 
course  of  time ;  in  both  cases  the  filling  fails  perfectly  to  answer  its 
purpose  in  the  preservation  of  the  tooth. 

The  enamel  edges  of  every  cavity,  in  preparing  it  for  the  introduc- 
tion of  a  filling,  should  be  smoothed  by  means  of  enamel  chisels  or  the 
margin  chisels,  or  the  stone  wheels  and  points,  so  that  it  may  be 
somewhat  countersunk.  Too  much  care  cannot  be  taken  to  properly 
prepare  the  enamel  edges,  as  the  perfection  of  the  filling  depends  in  a 
great  measure  upon  the  adaptation  of  the  gold  to  such  edges  or 
margins. 

It  is  preferable,  in  many  cases  of  front  approximal  fillings,  to  cut 
away  the  inner  angles  of  the  tooth,  thus  avoiding  the  injury  to  the  ex- 
ternal appearance  of  the  tooth  caused  by  the  file,  etc.  Upon  completion 
of  the  operation,  the  surface  thus  cut  is  perfectly  polished,  as  every  filled 
or  cut  surface  upon  the  teeth  should  be,  and  so  shaped  as  to  be  kept 
readily  cleansed  with  the  brush  or  with  floss  silk.  It  is  also  very  im- 
portant that  all  the  edges  of  cavities  should  be  smooth  and  polished 
before  and  after  the  introduction  of  the  filling. 

,  All  debris  accumulating  during  the  cutting  away  of  softened  dentine 
and  the  formation  of  the  cavity  should  be  removed,  either  by  the 
syringe  with  tepid  water,  or  blasts  of  air,  the  latter  being  preferable 
where  it  is  desirable  to  keep  the  cavity  dry  during  the  entire  excava- 
tion. 

In  forming  a  cavity  for  the  reception  of  cohesive  gold  foil,  it  is  very 
necessary  that  it  should  be  of  such  a  shape  as  to  retain  securely 
the  first  gold  introduced,  and  to  accomplish  this,  one  or  more  small 
cavities,  called  retaining  points,  are  made  within  the  larger  cavity. 
These  retaining  points  in  many  cases  afford  anchorage  for  the  entire 
mass  of  gold  composing  the  filling,  and  in  every  case  where  these 
forms  of  gold  are  used,  they  are  the  support  in  the  building  up  from 
the  bottom  to  the  orifice  of  the  cavity. 


458 


DENTAL,   SURGERY. 


These  retaining  points  are  formed  in  the  dentine  by  means  of  a 

small,  square,  chisel-edged  spear,  or  spear-shaped  drills,  and  can  very 

Fi(j_  268.  often   be   made 

of  one-sixteenth 
of    an    inch  in 
depth ;     a    less 
depth,  however, 
will   answer   in 
many     cases. 
One     of    these 
retaining  points 
in   connection  with  one  or  two  under-cuttings  on  the  opposite 
wall  will  be  suiBcient  in  some  cavities,  while  in  others  two  or 
three  are  required.     The  gold  should  be  introduced  into  these 
retaining  points  in  such  a  manner  as   to   form,  when  they 
are  filled,   solid  masses  of  metal,  which  would  require  con- 
siderable force   to   dislodge  them.     Upon  these  solid  masses 
the  gold  filling  the  cavity  is  built. 

Fig.  268  represents  a  set  of  Dr.  E.  S.  Talbot's  Margin 
Chisels  and  Pluggers,  for  cutting,  rounding,  and  smoothing 
the  edges  of  cavities,  leaving  them  in  a  condition  to  receive 
the  gold  which  should  be  adapted  accurately  to  the  mar- 
gins. 

Protecting  Cavities  from  Moisture. — The  first  step  in  this 
operation  is  to  wipe  the  mucous  membrane  covering  the  parts 
about  the  tooth  to  be  filled  perfectly  dry,  as  well  as  the  mouth 
of  the  duct  of  the  nearest  salivary  gland,  from  which  saliva 
may  flow  in  such  a  manner  as  to  interfere  with  the  opera- 
tion of  filling  the  cavity.  Before  the  introduction  of  the 
rubber-dam  the  following  method  was  pursued,  to  protect 
cavities  from  moisture  :  Over  the  mouth  of  the  duct,  a  roll  of 
bibulous  paper  was  placed,  upon  which  rested  one  part  of  a 
napkin,  which  was  so  arranged  about  the  tooth  as  to  prevent 
the  mucous  secretions  from  reaching  the  cavity.  The  napkin 
was  held  in  place  by  the  thumb  and  fingers  of  the  left  hand. 
The  remaining  portion  of  the  napkin  could  be  used  to  prevent 
the  breath  from  coming  in  contact  with  the  material  used  for 
filling,  as  well  as  the  cavity.  When  this  was  accomplished, 
the  cavity  was  dried,  as  hereafter  described,  and  was  then 
ready  for  the  filling.  Much  more  difficulty  was  met  with 
in  protecting  cavities  in  the  inferior  teeth  from  moisture  than 
in  the  case  of  the  superior,  and  various  appliances  were  devised  to 
overcome  it. 


TEEATMENT   OF   DENTAL   CARIES. 


459 


The  common  saliva  pump  (Fig.  269)  is  used  to  remove  the  saliva 
as  it  accumulates  in  the  lower  part  of  the  mouth,  and  consists  of  a 
glass  tube  with  an  elastic  bulb. 


Fig.  270. 


Miipir 


Fig  270  represents  a  very  superior  saliva  pump.  A,  bottle  or 
reservoir.  C,  clamp,  furnished  at  its  upper  and  lower  ends  with 
eight  steel  pins,  E,  F,  to  secure  it  to  the  upholstery  of  a  chair,  so 
that  it  cannot  be  detached  by  any  accidental  force.  When  used,  the 
hard  rubber  mouth-tube,  I,  is  held  in  the  mouth  by  one  hand  of  the 
patient,  and  the  bulb,  K,  in  the  other.  Whenever  saliva  accumu- 
lates, the  patient  presses  the  bulb,  and  the  saliva  flows  into  the  reser- 
voir. The  reservoir  is  emptied  by  unscrewing  the  cap,  B.  A  very 
ingenious  improvement  on  this  instrument  has  been  recently  made 
for  attachment  to  the  "  fountain  spittoon,"  the  current  of  the  water 
causing  a  constant  and  automatic  suction,  by  which  the  instrument  is 
operated  and  the  mouth  kept  free  from  saliva. 


460 


DENTAL   SUEGERY. 


Fig.  271. 


Fig.  271  represents  the  Ad- 
justable Fountain  Spittoon 
with  the  Saliva  Pump  attach- 
ment. 

The  Rubber  Dam. — For 
one  of  the  most  simple,  yet 
effective,  appliances  for  con- 
trolling the  flow  of  saliva, 
and  protecting  cavities  from 
moisture,  we  are  indebted  to 
Dr.  S.  C.  Barnum.  It  consists 
of  nothing  more  than  a  thin 
sheet  of  India-rubber,  of  good 
quality,  that  it  may  possess 
sufficient  strength  and  not  tear 
easily,  and  of  a  thickness 
double  that  of  letter  paper. 

Some  distance  from  the 
edge  of  the  sheet,  which  is 
from  four  to  eight  inches 
square,  one,  two  or  more  holes 
are  made,  through  which  the 
crowns  of  the  teeth  are  passed, 
when  it  is  applied  to  the 
mouth. 

The  holes  made  in  the 
rubber  should  be  about  one- 
tenth  smaller  in  diameter  than 
the  necks  of  the  teeth  they  are 
to  embrace. 

Fig.  272  represents  the 
Rubber  Dam  in  position, 
supported  by  means  of  a 
"  dam-holder,"  devised  by 
Dr.  Cogswell. 

It  is  better  in  all  cases 
to  make  several  of  these  holes 
in  the  sheet,  in  order  to  in- 
clude Avithin  the  coffer-dam 
formed  when  the  sheet  is  in 
position  the  crowns  of  the 
teeth  adjoining  the  one  in 
which  the  cavity  to  be  filled 


TREATMENT   OP   DENTAL  CAEIES. 


461 


is   situated.     When  the  crowns  Fig.  272. 

of  the  teeth  approximate  closely, 
the  holes  should  be  made  about 
one-eighth  of  an  inch  apart ;  if 
some  space  exists  between  the 
crowns,  the  holes  may  be  made 
at  a  greater  distance  from  each 
other.  These  holes  may  be 
formed  in  the  rubber  by  means 
of  a  small  chisel-edged  punch, 
by  burning  with  a  heated  instru- 
ment, or  by  the  appliances  repre- 
sented in  Figs.  273,  274,  275 
and  276. 

The  rubber,  thus  prepared,  is 
carried  between  the  teeth  by 
either  a  thin,  flat  burnisher, 
or,  which  is  better,   by   waxed 

floss  silk,  and  the  margins  of  the  holes  pressed  gently 
edges  of  the  gums,  in  the  direction  of  the  roots  of  the 


under  the  free 
teeth. 


Fig.  273. 


Triplex  Bubber-Dam  Punch. 


462 


DENTAL  SUEGERY. 

Fig.  274. 


Fig.  275. 


Ainsworth's  Ktjbbee-Dam  Ptjnch. 


TREATMENT   OF    DENTAL   CARIES. 


463 


These  margins  should  be  secured  to  the  necks  of  the  teeth  by  means 
of  waxed  floss  silk  tied  around  them,  or  by  the  use  of  suitable  clamps, 
such  as  are  now  manufactured  for  that  purpose. 


Fig.  276. 


W  1 


The  Guide  Bubber-Dam  Punch. 


Fig.  277  represents  an  "  Applier  "  for  the  use  of  waxed  floss  silk  in 
adjusting  the  Rubber  Dam. 


Fig.  277, 


Fig.  278  represents  some  of  the  many  forms  of  Rubber  Dam-Clamps 
used  for  securing  the  rubber  dam  to  the  necks  of  teeth. 


464 


DENTAL   SURGERY. 
Fig.  278. 


Forms  of  these  clamps  are  made  with  tongue-guards,  such  as  are 
shown  in  Fig.  279. 

Fig.  279. 


TKEATMENT    OF    DEXTAL    CARIES. 

Fig.  280. 


465 


Fig.  280  represents  the  Rubber-Dam  Clamp  Forceps,  by  means  of 
30 


466 


DENTAL   SURGERY. 


which  the  clamp,  in  connection  with  the  rubber  dam,  is  placed  in  posi- 
tion on  the  tooth. 

Fig.  281  represents  Dr.  E.  Parmly  Brown's  Universal  Rubber-Dam 
Screw-Clamp,  which  may  be  adjusted  to  any  tooth  in  the  mouth, 
clasping  several  teeth  at  the  same  time,  and  is  applicable  to  loose  or 
tender  and  not  fully  erupted  teeth. 

Several  other  simple  appliances  are  in  use  to  protect  cavities  from 
moisture,  such  as  wooden  wedges  forced  between  the  necks  of  the 
teeth,  and  waxed  cord  surrounding  the  tooth  in  which  the  cavity  is 
situated,  and  passing  to  an  adjoining  tooth;  also  a  band  of  rubber 

Fig.  281. 


lev^i 


cut  from  tubing,  which  is  placed  high  up  on  the  neck  of  the  tooth  and 
then  carried  around  an  adjoining  one.  Two  of  these  bands,  acting  in 
opposite  directions,  answer  better  than  a  single  one,  and  in  many  cases 
effectually  protect  the  cavity  from  moisture. 

Drying  Cavities. — After  every  particle  of  decomposed  dentine  has 
been  removed,  the  cavity  should  be  thoroughly  cleansed  before  the  filling 
is  introduced.  This  may  be  done  by  first  injecting  tepid  water  into  it 
with  a  properly  constructed  syringe,  and  afterward  wiping  it  dry  with 
a  small  lock  of  absorbent  cotton  fixed  upon  the  point  of  a  probe  or 
excavator ;  or  the  cavity  may,  in  the  first  place,  be  wiped  with  a  little 


INSTRUMENTS   FOR   INTRODUCING    GOLD. 


467 


raw  cotton  moistened  with  water,  and  afterward  with  absorbent  cotton. 
The  application  of  the  cotton  should  be  followed  by  that  of  Japanese 
bibulous  paper,  which  has  a  very  loose,  absorbent  texture,  and  may  be 
folded,  for  convenience,  in  the  form  of  a  rope,  from  which  the  moistened 
end  can  be  torn  after  each  insertion.  Tissue  or  bibulous  paper  absorbs 
moisture  more  perfectly  than  cotton.  The  absorbing  qualities  of  cotton, 
however,  may  be  increased  by  boiling  it  for  fifteen  or  twenty  minutes 
in  a  tolerably  strong  alkaline  solution  ;  this  done,  it  should  be  thor- 
oughly dried  before  using;  or  by  saturating  it  with  sulphuric  ether  to 
remove  the  natural  oil.  Several  materials  have  been  of  late  years  used 
in  drying  cavities,  such  as  prepared  flax,  fine  and  white,  with  a  long, 
absorbent  fibre,  prepared  spunk,  absorbent  cotton.  Fig.  282  represents 
a  Hot-air  Syringe  for  drying  cavities.  To  fill  this  syringe  with  heated 
air,  the  turret  of  the  air-chamber  is  held  in  the  flame  of  a  spirit-lamp ; 
the  turret  being  provided  with  a  metallic  valve,  recedes  as  the  bulb, 
after  being  compressed,  fills  with  air,  and  allows  the  flame  to  be  drawn 

Fig.  282. 


into  the  chamber ;  the  air-chamber  is  divided  by  partitions  of  wire 
gauze,  which  act  as  retainers  of  heat.  It  is  desirable  that  the  cavity 
should  be  perfectly  dry  before  the  filling  is  introduced. 


INSTRUMENTS    FOR   INTRODUCING   AND   CONSOLIDATING   GOLD. 

For  introducing  and  consolidating  non-cohesive  gold  foil,  a  number 
of  instruments  are  required,  which  should  be  sufiiciently  strong  to 
resist  any  amount  of  pressure  the  dentist  can  safely  exert  in  the  opera- 
tion. Hand  instruments  should  have  round  or  octagonal  handles, 
large  enough  to  prevent  the  liability  of  being  broken  and  to  enable 
him  to  grasp  them  firmly.  Their  points  should  vary  in  size,  though 
none  should  be  very  large.  Several  should  be  straight,  but  for  the 
most  part  they  require  to  be  curved — some  very  slightly,  others  forming 
with  the  shaft  of  the  instrument  an  angle  of  ninety  degrees.  Fig.  283 
represents  a  set  of  small-pointed  hand  pluggers.  For  other  forms  the 
reader  is  referred  to  the  chapter  on  "  Filling  Individual  Cavities." 

Plugging  instruments  as  received  from  the  instrument  makers  have 


468 


DENTAL   SURGERY. 


usually  a  temper  which  will  not  permit  them  to  be  bent.     It  will  add, 

we  think,  greatly  to  the  value  of  the  instrument,  if  the  practice  of  Dr. 

Maynard  were  more  generally  adopted.     He    gives  to  the  extreme 

point  a  hard  temper  (straw  color)  to  prevent  it  from  wearing ;  for  a 

little  distance,  say  one  to  three-quarters  of  an  inch,  a  spring  temper  is 

given  (purple  or  blue  color)  to  insure  strength  when  the  shape  is 

delicate ;  the  rest  of  the  instrument  is  left  soft,  so  as  to  admit  of  being 

bent  (with  pliers)  in  the  direction  best  suited  for  that  particular  point 

in  any  given  operation. 

Fic.  283. 


Most  of  them  should  have  a  slim  wedge  shape ;  some,  however,  both 
of  the  straight  and  curved  instruments,  should  have  blunt  serrated 
points,  and  a  few  should  have  highly  polished  oval  points,  for  finishing 
the  surface  of  fillings.  Formerly,  most  dentists  employed,  for  intro- 
ducing and  consolidating  the  gold,  simple  blunt-pointed  pluggers  ;  but 
it  is  impossible  with  such  instruments  to  make  a  filling  as  firm  and 
solid  as  it  should  be  for  the  perfect  preservation  of  a  tooth,  especially 
if  the  cavity  is  large.  From  one-fourth  to  one-half  more  gold  can  be 
introduced  into  a  tolerably  large  cavity  with  a  wedge-pointed  than 
with  a  blunt-pointed  instrument. 


INSTRUMENTS   FOR   INTRODUCING   GOLD. 


469 


Fig.  284  represents  an  excellent  set  of  points  designed  by  Professor 
James  H.  Harris  for  use  in  solid  or  socket  handles,  and  also  with  the 
automatic  or  hand  mallet,  and  although  intended  for  cohesive  gold, 
can  also  be  used  for  the  non-cohesive. 


Fig.  284. 


This  general  description  will  serve  to  convey  a  tolerably  correct 
idea  of  the  kind  of  instruments  required  for  the  operation. 

Instruments  having  serrated  points  are  required  for  filling  teeth 
with  crystal  or  sponge  gold,  and  with  cohesive  gold  foil. 


Fig.  285. 


Fig.  285  represents  some  knurled  handles  for  cone-socket  plugger 
points. 


470 


DENTAL   SURGEEY. 


airn 


Fig.  286. 

f  f  /* 


Fig.    286    represents    Dr.    R.   W.   Vamey's    set    of 
Pluggers  for  the  cohesive  form  of  gold  foil. 

Fig.  287. 


Fig.  287  represents  Dr.  Marshall  H.  Webb's  set  of 
Pluggers,  also  fot  the  cohesive  form  of  gold  foil. 

Fig.  288  represents  Dr.  Chappelle's  Malleting  Shaft 
Pluggers,  for  the  use  of  cohesive  gold,  especially  No.  30 
rolled  cohesive  gold,  cut  in  strips  tVi  h  xV  inch  wide  and 
one  inch  long. 

Fig.  289  represents  a  combined  foil  carrier  and 
plugger,  for  taking  up  pieces  of  gold  and  placing  them 
in  the  cavity,  and  partially  condensing  them. 


MANNER  OF  PREPARING,  INTRODUCING  AND  CONSOLI- 
DATING GOLD,  AND  FINISHING  THE  SURFACE  OF 
THE   FILLING. 

Non- Cohesive  Gold  Foil. — The  operator,  being  pro- 
vided with  the  necessary  instruments,  should  cut  thi.'^^ 
form  of  gold,  with  a  pair  of  foil  scissors,  into  strips  con- 
taining from  one-fourth  of  a  sheet  to  one  whole  sheet. 
Each  of  these  should  be  loosely  rolled  or  folded  togethei 
lengthwise,  by  the  aid  of  a  Foil  Folder  or  Spatula  (Fig. 


MANNER   OF   INTRODUCING   GOLD. 


471 


Fig.  288. 


290),  on  a  piece  of  soft  spunk,  covered  with  chamois  skin  or  white 
kid — the  foil  scissors  and  spatula  have  recently  been  combined  into 
one  instrument — and  after  the  cavity  has  been  properly  cleansed 
and  dried,  the  end  of  one  fold  should  be  introduced  and  carried  to 

Fig.  289. 


the  bottom  of  the  cavity,  with  a  straight  or  curved  wedge-pointed 
instrument ;  the  roll  on  the  outside  should  then  be  folded  on  the 

Fig.  290. 


part  first  inserted.  The  folding  should  be  commenced  on  one 
side  of  the  cavity,  and  the  inner  end  of  each  fold  taken  to 
the  bottom,  the  outer  extending  nearly  a  twelfth  or  an  eighth  of 
an  inch  on  the  outside  of  the  orifice;  thus,  fold  after  fold  is 
introduced,  until  no  more  can,  in  this  manner,  be  forced  into  the 
cavity.  Having  proceeded  thus  far  in  the  operation,  the  instru- 
ment should  be  forced  through  the  centre  of  the  filling,  and  the 
gold  firmly  pressed  against  the  walls  of  the  cavity.  The  opening 
thus  made  should  be  filled  in  the  manner  as  first  described,  and 
this  time  it  should  be  packed  in  as  tightly  as  possible.  This 
done,  the  operator  should  endeavor  to  force  a  small,  wedge-pointed 
instrument  in  the  centre  of  the  filling,  until  he  has  tried  every 
part  of  the  plug ;  filling,  as  he  proceeds,  every  opening  which  he 
makes,  and  exerting,  in  the  packing  of  the  gold,  all  the  pressure 


472  DENTAL  SURGERY. 

which  he  can  apply  without  endangering  the  tooth.  If  one  roll 
or  fold  of  gold  is  not  enough,  he  should  take  another  and  another, 
until  the  cavity  is  thoroughly  filled.  When  the  walls  of  a  cavity  are 
frail,  it  is  the  practice  of  some  operators  to  introduce  the  gold  rather 
loosely,  and  to  depend  upon  surface  condensing  to  obtain  the  neces- 
sary solidity.  But  it  is  better  to  well  condense  every  fold  imme- 
diately after  it  is  carried  to  its  proper  place  in  the  cavity ;  such 
condensing  will  often  render  the  use  of  the  wedge-shaped  instrument 
unnecessary. 

The  advantage  to  be  derived  from  introducing  the  gold  in  this 
manner  is  obvious.  By  extending  the  folds  from  the  orifice  to  the 
bottom  of  the  cavity,  the  liability  of  the  gold  to  crumble  and  come  out 
is  efiectually  prevented  ;  and  by  introducing  it  with  a  wedge-pointed 
instrument,  it  may  be  carried  into  all  the  depressions  of  the  walls  of 
the  cavity,  and  rendered  altogether  more  solid  than  it  could  otherwise 
be  made.  The  cohesiveness  of  the  gold  may  be  increased  by  slightly 
warming  in  the  flame  of  a  spirit  lamp,  after  it  has  been  made  into 
rolls  or  folds. 

After  the  cavity  has  been  completely  filled,  every  portion  of  the 
projecting  part  of  the  gold  must  be  thoroughly  consolidated,  before  it 
is  allowed  to  become  wet,  with  a  small,  blunt-pointed  instrument, ' 
straight  or  curved,  as  may  be  most  convenient ;  or,  if  the  filling  is  in 
the  approximal  side  of  a  tooth,  it  may  be  compressed  with  the  angle  of 
the  point  of  the  plugger,  making  the  adjoining  organ,  to  a  slight  extent, 
a  kind  of  fulcrum  for  the  instrument.  After  the  filling  has  been  thus 
consolidated,  as  long  as  it  can  be  made  to  yield  in  the  least  to  the 
pressure  of  the  instrument,  the  protruding  parts  may  be  scraped  or 
filed  ofi",  down  to  the  tooth,  so  as  to  form  a  smooth,  uniform,  gently 
swelling  or  perfectly  flat  surface.  Fig.  313  (p.  490)  represents  a  number 
of  finishing  files.  If  in  this  part  of  the  operation  any  portion  of  the 
gold  should  crumble  or  be  dislodged,  which  it  will  not  do  if  it  has  been 
properly  introduced  and  consolidated,  the  injury  may  be  repaired  by 
making,  in  the  part  of  the  plug  where  it  has  occurred,  an  opening,  and 
filling  it,  or  by  the  removal  of  the  whole  of  the  filling  and  the  intro- 
duction of  another.  If  any  portions  of  the  gold  have  been  forced  over 
the  edge  of  the  orifice  of  the  cavity,  they  should  be  carefully  removed, 
either  with  a  file  or  sharp-pointed  cutting  instrument  suited  to  the  pur- 
pose. This  precaution  should  never  be  neglected,  especially  when  the 
filling  is  in  the  approximal  surface  of  a  tooth,  where  a  portion  of  the 
gold  is  very  liable  to  be  forced  up  or  down  upon  the  neck,  and  under 
the  gum.  If  the  filling  is  located  on  a  masticating  surface,  a  flat  and 
level  gold  surface  will  answer  the  best  purpose  in  preserving  the  tooth- 
structure  ;  if  upon  an  approximal  surface,  the  filling  should  be  contour, 


MANNER  OF   INTRODUCING   GOLD.  473 

as  a  general  rule.  Soft  or  non-cohesive  gold  foil,  in  the  form  of  the 
ribbon  or  loosely-rolled  cylinders,  is  frequently  used  in  connection  with 
cohesive  gold  foil,  as  a  base  upon  which  to  build  the  latter  form  of  gold. 
This  combination  is  especially  applicable  in  the  case  of  cavities  upon  the 
approximal  surfaces  of  the  teeth  and  which  extend  to  the  gum.  The 
soft  or  non-cohesive  gold  in  such  cases  is  employed  to  cover  over  the 
cervical  walls,  being  first  introduced  into  one  of  the  angles  of  the 
cavity,  until  this  wall  is  completely  covered,  when  mallet  force  is  em- 
ployed to  condense  the  mass,  which  has  been  introduced  with  a  fine 
foot-plugger.  On  this  base  of  non-cohesive  gold,  pieces  or  pellets,  or 
the  ribbon  of  cohesive  gold,  are  condensed,  and  the  filling  completed 
with  the  latter  form  of  gold.  The  non-cohesive  gold,  owing  to  its 
quality  of  adaptability,  is  capable  of  being  closely  packed  against  the 
most  vulnerable  walls  of  cavities,  where  it  answers  a  better  purpose 
in  the  preservation  of  the  teeth  than  the  cohesive  forms  would  do  in 
the  same  location. 

Cylinder  Filling. — The  method  of  filling  cavities  with  non-cohesive 
gold  foil  in  the  form  of  cylinders  is  a  favorite  one  with  many  operators, 
and  is  in  some  cases,  especially  grinding  surface  cavities  with  firm 
walls,  preferable  to  that  of  the  fold  or  rope.  A  common  method  of 
preparing  these  cylinders  is  to  fold  lengthwise,  in  the  form  of  a  ribbon, 
either  the  third,  half,  or  whole  of  a  leaf  of  No.  4  or  6  gold  foil ;  the 
width  of  the  ribbon  determines  the  length  of  the  cylinders.  One  end 
of  this  ribbon  is  then  held  between  the  thumb  and  index  finger  of  the 
left  hand,  and  wound  upon  a  three-  or  four-sided  broach  until  the 
cylinder  thus  formed  is  of  the  size  desired,  when  the  remaining  portion 
of  ribbon  is  torn  off". 

The  cylinders  should  be  a  little  longer  than  the  cavity  is  deep,  in 
order  to  allow  for  surface  condensing.  The  density  of  the  cylinders 
depends  upon  the  firmness  with  which  the  ribbon  is  wound  upon  the 
broach  ;  by  winding  it  loosely  upon  the  broach,  soft  cylinders  are 
formed,  to  be  placed  in  contact  with  the  walls  of  the  cavity,  while  the 
hard  cylinders  made  by  firmer  winding  are  introduced  inside  of  the 
soft,  and  form  the  centre  of  the  filling.  Different  forms  as  well  as  sizes 
of  cylinders  are  necessary  in  every  case,  cone-shaped  as  well  as  the 
true  cylindrical.  The  cone-shaped  cylinders  are  useful  where  there  is 
an  under-cutting,  and  also  for  completing  the  introduction  of  the  gold. 

These  cone-shaped  cylinders  are  formed  by  winding  the  ribbon  back 
from  the  j)oint  of  the  broach,  which  should  taper  slightly,  in  order 
that  the  cylinder  when  completed  may  be  easily  detached. 

Loosely  rolled  cylinders,  prepared  ready  for  use,  can  be  obtained  of 
manufacturers  (Fig.  291). 


474 


DENTAL  SURGERY. 

Fig.  291. 


These  loose  cylinders  are  useful  applied  to  the  cervical  Avails  of 
approximal  cavities,  as  a  base  upon  which  to  build  cohesive  gold  foil. 
Also  the  Blocks  or  Mats  represented  in  Fig.  292. 


Fig.  292. 


Size  1. 


Size  2. 
□ 


Size  3. 


u 


For  placing  the  cylinders  into  their  proper  places  in  the  cavity,  the 
introducing  pliers  are  necessary,  which  have  smooth  points  bent  at 
such  an  angle  as  will  permit  of  their  being  used,  when  closed,  as  a 
condensing  point. 

The  cavity  being  prepared  for  the  gold  and  properly  protected  from 
moisture,  one  of  the  soft  cylinders  is  carried  into  it  with  the  pliers,  and 
placed  in  such  a  position  that  one  end  rests  on  the  bottom  and  the 
other  protrudes  from  the  orifice.  Pressure  in  the  direction  of  the  wall 
against  which  the  cylinder  rests  is  then  made  with  the  closed  points 
of  the  pliers,  and  afterward  with  a  condensing  instrument  having 
either  a  smooth,  wedge-shaped  point,  or,  with  what  is  better,  a  serrated 
point,  such  as  are  represented  in  Fig.  294.  When  the  first  cylinder 
introduced  has  been  well  condensed  against  one  of  the  walls  of  the 
cavity,  others  are  introduced  and  condensed  in  succession,  until  these 
walls  are  covered  by  the  soft  cylinders.  The  hard  cylinders  are  then 
disposed  round  the  cavity  in  the  same  manner  as  the  soft  ones,  until  it 
diminishes  so  much  as  to  render  it  necessary  to  form  a  cavity  in  the 
centre  of  the  gold  already  introduced,  by  means  of  a  smooth,  wedge- 
shaped  instrument,  such  as  is  represented  in  Fig.  293.     The  cavity 

Fig.  293. 


formed  by  this  instrument  is  then  filled  with  a  small,  dense  cylinder, 
and  successive  openings  are  thus  made  and  filled,  until  no  more  gold 
can  be  introduced,  when  the  protruding  ends  of  the  cylinders  are  con- 


MANNER   OF   INTRODUCING   GOLD.  475 

densed  by  pressure  applied  in  the  direction  of  the  bottom  of  the  cavity. 
The  surface  of  the  filling  is  then  finished  in  the  manner  to  be  described 
hereafter.  To  obtain  an  extremely  dense  surface,  crystal  or  sponge 
gold  may  be  added  to  the  surface  of  a  cylinder  filling,  before  such  a 
surface  is  condensed,  by  introducing  it  into  the  interstices  between  the 
cylinders  projecting  above  the  margin  of  the  cavity,  and  then  applying 
mallet  force. 

When  the  cavity  is  of  considerable  depth  and  small  in  diameter,  or 
the  bottom  is  uneven,  pellets  of  gold  may  be  introduced  and  condensed 
upon  the  bottom  until  the  cavity  is  about  one  third  filled.  By  this 
method  the  gold  is  better  adapted  to  the  bottom  of  the  cavity  than  by 
placing  the  ends  of  the  cylinders  upon  an  uneven  surface.  The  surface 
condensing  of  cylinder  fillings  should  be  made  with  small-pointed 
condensing  instruments,  and  any  opening  it  is  possible  to  make  with 
them  be  filled  with  small,  dense  cylinders. 

Redman's  Method  of  Cylinder  Filling. — The  following  is  Dr.  W.  G. 
Redman's  description  of  his  method  of  preparing  and  introducing  non- 
cohesive  gold  foil  in  the  form  of  cylinders,  which  differs  from  the  one 
before  described : — 

"  The  instruments  necessary  for  preparing  the  cylinders  by  this 
method  consist  of  half  a  dozen  of  steel  rods,  six  inches  long,  and  of  the 
following  sizes :  Nos.  2,  4, 6,  8,  10, 12,  White's  burr  gauge  plate,  and  a 
short,  fine,  tapering  broach. 

"For  introducing  the  cylinders,  a  pair  of  introducing  pliers,  having 
points  serrated  upon  the  inside,  are  necessary,  and  for  lateral  condens- 
ing, while  introducing  the  cylinders,  a  narrow  foot  instrument  lightly 
serrated  by  means  of  a  fine  file,  the  serrations  being  rubbed  down  with 
emery  paper,  together  with  several  sharp-pointed,  cone-shaped  instru- 
ments for^examining,  and  if  necessary,  piercing  the  filling  for  the  in- 
troduction of  more  gold  before  commencing  the  surface  condensing. 
This  instrument  is  represented  in  Fig.  293. 

"  For  surface  condensing  in  crown  cavities,  after  all  the  cylinders 
are  introduced,  instruments  with  large  and  deeply  serrated  points  are 
necessary,  which  are  to  be  followed  by  smaller  ones  with  points  shaped 
and  serrated  like  an  ordinary  burr  drill. 

"  For  approximal  surface  cavities,  a  thin,  flat,  serrated  condensing 
instrument,  such  as  is  represented  in  Fig.  294,  is  necessary,  together  with 
a  small,  square,  wedge-shaped  instrument,  and  ordinary  right  and  left 
condensers." 

Fig.  294  represents  a  complete  set  of  Redraau's  instruments. 

"Preparation  of  the  Cylinders. — It  is  seldom  necessary  that  a  cyl- 
inder should  contain  more  than  one-third  of  a  sheet  of  No.  3  gold  foil. 
Any  number  of  small  cylinders  prepared  by  this  method  may  be  placed 


476 


DENTAL  SUEGERY. 


side  by  side,  and  condensed  by  lateral  pressure  more  readily  than  the 
same  quantity  of  gold  could  be,  if  formed  into  but  one  cylinder. 
Small  cylinders  can  also  be  adapted  to  the  walls  of  the  cavity  much 
better  than  long  ones.  The  gold  from  which  they  are  formed  should 
be  as  soft  and  tough  as  it  can  be  manufactured,  and  does  not  require 
to  be  re-annealed  either  in  the  leaf,  ribbon  or  cylinder.  In  preparing 
the  ribbon,  a  leaf  of  gold  is  cut  into  three  pieces,  each  of  which  is 
rolled  diagonally  on  a  steel  rod,  the  diameter  of  which  should  be  the 
same  as  the  depth  of  the  cavity  to  be  filled.     The  rod  is  withdrawn 


Fig.  294. 


©         o 


from  the  cylinder  by  passing  the  thumb  and  forefinger  gradually  to 
the  free  end,  and  reversing  the  movement  of  the  rod  in  winding  the  gold 
about  it.  The  long  cylinder  thus  formed,  and  held  between  the  thumb 
and  forefinger,  is  now  rolled,  without  being  flattened  previously,  on  a 
rod  of  a  size  necessary  to  give  a  proper  length  to  the  small  cylinder  it 
is  desired  to  make.  As  soon  as  the  cylinder  is  withdrawn  from  the 
rod,  it  is  pressed  slightly  between  the  thumb  and  forefinger,  in  order  to 
give  it  an  oval  form,  and  also  to  prevent  its  unfolding.  To  form 
smaller  cylinders,  the  ribbon  is  cut  into  such  lengths  as  are  necessary 
to  make  the  size  desired.      Some  of  the   cylinders  should  be  dense 


MANNER   OF   INTEODUCING   GOLD. 


477 


enough  to  permit  of  their  being  forced  into  their  places  when  the  in- 
troduction of  the  gold  is  nearly  completed.  Dense  cylinders  may  be 
made  from  the  oval  form  by  bending  the  sides  together  with  the  intro- 
ducing pliers,  or  by  the  common  method  of  folding  the  ribbon  and 
winding  it  tightly  on  a  broach. 

"  Preparation  of  Cavity. — The  walls  should  be  as  nearly  perpendic- 
ular as  possible,  and  without  much  under-cutting  ;  retaining  points 
are  unnecessary.  Slight  grooves  in  opposite  walls  are  sufficient  to  retain 
the  filling. 

"  Litroduciiiy  the  Cylinders. — The  cylinders,  in  using  this  method, 
are  carried  with  the  pliers  to  a  point  in  the  cavity  furthest  from  the 
operator,  and  placed  in  such  a  manner  as  will  enable  him  to  apply  the 
pressure  against  the  free  ends  ;  the  opposite  ends  of  the  cylinders  being 
in  contact  with  the  posterior  wall  of  the  cavity."  "  The  pressure 
applied  during  the  introduction  of  the  gold  should  always,  when  prac- 
ticable, be  in  a  direction  from  the  operator."  "After  introducing  a 
sufficient  quantity  of  gold  to  fill  a  third  or  half  of  the  cavity,  before 
making  lateral  pressure,  care  should  be  taken  to  adapt  the  gold  well  to 
the  bottom."  "  Lateral  pressure  is  then  made  and  more  gold  intro- 
duced until  the  cavity  is  filled ;  the  last  cylinder  used  being  a  dense 
one."  "  The  gold  should  be  so  evenly  and  solidly  introduced  that 
there  will  be  no  necessity  for  using  the  wedge-shaped  instrument ; 
should  the  use  of  this  instrument,  however,  be  necessary,  the  opening 
made  by  it  may  be  filled  with  one  of  the  dense  cylinders  or  with  the 
strip."  "  After  all  the  gold  necessary  is  introduced,  the  surface  of  the 
filling  should  be  condensed  with  a  large  and  deeply  serrated  instru- 
ment, and  followed  by  one  of  smaller  size  and  finer  serrations." 

The  Herbst  Method. — Dr.  Herbst,  of  Germany,  has  recently  introduced 
a  method  of  manipulating  a  quality  of  soft  or  non-cohesive  gold,  in  the 
form  of  cylinders,  made  by  Wollrab,  of  Bremen,  to  which  the  name 
"rotation  gold  filling"  has  been  given. 

Fig.  295  represents  the  instruments  used  in  the  Herbst  method, 

Fig.  295. 

II 


J 

7         8        9        10       11 

smooth,  but  not  polished,  and  some  of  the  points  are  quite 
these  instruments,  when  made  of  steel,  become  coated  with 


478  DENTAL  SURGERY. 

the  gold,  by  its  adhesion,  they  can  be  cleansed  during  their  use  by  rub- 
bing their  points  on  a  piece  of  block  tin,  or  upon  fine  crocus  cloth  ;  it 
has  also  been  suggested  to  plate  the  points  with  gold.  This  German 
gold  appears  to  become  cohesive  by  rubbing  it  with  the  instruments, 
which  have  points  like  burnishers,  and  are  rotated  in  the  introduction 
and  consolidation  of  the  gold.  By  slightly  annealing  the  cylinders 
they  can  be  united,  and  even  hammered,  without  crumbling  in  pieces. 
The  cavities  into  which  this  form  of  gold  is  introduced  are  prepared 
in  the  usual  manner,  with  their  edges  smooth  and  slightly  rounded  off; 
deep  retaining  points  are  unnecessary,  and  but  few  pits  are  required. 
For  filling  an  ordinary  cavity  in  a  grinding  surface,  the  quantity  of  gold 
first  introduced  should  be  large  enough  to  be  retained  when  con- 
densed, without  support  from  an  instrument,  which  is  accomplished 
bv  packing  the  cavity  loosely,  but  quite  full  of  the  cylinders,  when 
the  instruments  numbered  2,  3,  or  4  (Fig.  295),  by  a  slow  rotation, 
burnish  the  gold  against  the  walls.  A  second  layer  of  gold  is  made  to 
adhere  to  the  surface  of  the  first  gold  introduced,  by  the  use  of  the 
form  of  instrument  represented  by  numbers  5,  6,  7,  or  8,  by  rotating 
it  quickly  until  the  polished  surface  of  the  first  gold  introduced  has 
been  destroyed,  Avhen  the  second  layer  of  gold  will  adhere  to  it.  The 
filling  of  the  cavity  is  continued  in  this  manner  until  all  of  the  gold 
necessary  is  introduced  and  consolidated. 

For  filling  two  superior  incisor  cavities  in  opposite  approximal  sur- 
faces, after  being  prepared  in  the  usual  manner,  they  are  treated  as 
one  cavity,  by  introducing  the  gold  into  both  at  the  same  time 
(bridging  over),  first  securing  it  in  the  four  corners  or  angles  by 
rotation  with  the  instruments  represented  by  numbers  5,  6,  7,  or  8, 
according  to  the  size  required,  so  that  a  common  mass  of  gold  appears. 
The  fine-pointed  instrument,  No.  18,  is  then  inserted,  with  regular 
rotation,  into  this  mass,  between  the  two  teeth,  until  it  is  separated, 
when  thin  files,  or  disks  and  tape  are  employed  to  finish  the  surfaces 
of  each  filling. 

For  filling  two  similar  cavities  in  the  approximal  surfaces  of  bicuspids 
and  molars  a  matrix  is  used,  which  is  secured  in  place  between  the 
teeth  with  shellac,  one  cavity  being  first  filled  by  commencing  the 
introduction  of  the  gold  against  the  cervical  wall  or  border,  and 
condensing  against  the  matrix  at  that  point,  and  then  toward  the 
centre  of  the  crown.  The  first  cavity  being  filled,  the  shellac  is 
removed  and  the  remaining  cavity  filled  in  the  same  manner.  The 
rotation  and  pressure  of  the  instruments  appear  to  produce  sufficient 
heat  to  render  the  gold  cohesive,  and  it  is  claimed  that  a  filling  by  this 
method  and  with  this  quality  of  gold  can  be  inserted  very  quickly,  and 
that  it  is  impermeable  to  all  fluids. 


COHESIVE   GOLD    FOIL.  479 

Pellets. — Another  form  in  which  non-cohesive  gold  foil  is  used  is 
that  of  pellets,  which  are  formed  by  lightly  rolling  a  portion  of  a  sheet 
between  the  thumb  and  fingers.  They  are  made  of  different  sizes,  and 
when  placed  in  a  cavity  are  welded  together  by  means  of  pointed  or 
serrated  instruments.  It  is  necessary  that  the  first  pellets  introduced 
should  be  securely  anchored,  in  order  that  the  successive  ones  may  be 
built  upon  them ;  these  last  should  be  small  enough  to  allow  the  welding 
instrument  to  pass  through  them  to  the  gold  beneath. 

COHESIVE  GOLD    FOIL. 

Cohesive  gold  foil  is  well  adapted  for  all  shallow  cavities,  and  for 
restoring  lost  portions  of  the  crowns  of  teeth.  While  non-cohesive 
gold  is  retained  by  the  general  form  of  the  cavity,  cohesive  gold  is 
anchored  by  means  of  retaining  points  or  pits,  on  the  principle  of 
welding  one  piece  or  fold  to  another  until  the  required  quantity 
is  introduced.  The  number  of  retaining  pits  will  depend  upon  the 
form  of  cavity  to  be  filled,  varying  from  three  to  six.  The  depth 
of  these  retaining  points  will  also  depend  upon  the  strength  of  the 
walls  of  the  cavity,  as  will  also,  in  a  great  measure,  their  diameter ; 
as  a  general  rule,  a  greater  number  of  small  pits,  if  the  wall  is  weak, 
and  a  few  large  pits  where  the  wall  is  strong,  or  where  a  portion  of  the 
filling  has  to  withstand  great  force.  These  retaining  pits  are  made 
with  small,  square-edged  drills,  to  a  depth  corresponding  with  the 
diameter  of  the  drill,  and  in  a  direction  opposite  to  each  other,  and  in 
a  line  with  the  force  to  be  resisted.  Each  of  these  retaining  pits  is 
solidly  filled  with  pellets  of  a  suitable  size,  the  pieces  of  gold  being 
conveyed  to  the  cavity  by  means  of  the  introducing  pliers,  and  thor- 
oughly condensed  by  mallet  force.  The  retaining  pits  being  filled,  the 
gold  is  built  over,  from  one  to  the  other,  until  the  surface  upon  which 
they  are  located  is  covered,  which  secures  a  base  for  the  entire  filling. 
Larger  pellets  are  then  built  upon  this  base,  care  being  taken  to  adapt 
the  gold  perfectly  to  the  walls  of  the  cavity,  by  gradually  building  it 
somewhat  higher  against  the  walls  than  in  the  centre.  The  operation 
is  continued  in  this  manner  until  the  edge  of  the  cavity  is  reached, 
when  the  gold  is  built  up  in  the  centre  and  above  and  over  the  mar- 
gins, to  permit  of  its  being  so  cut  away  as  to  conform  to  the  original 
contour  of  the  surface  which  it  is  to  restore. 

The  cutting  away  of  the  surplus  gold  is  accomplished  by  means  of 
suitable  plug-finishing  files,  or  plug-finishing  burrs,  corundum  disks  or 
points,  Hindostan  or  Arkansas  stone  points,  etc.,  after  which  smoothing 
process  a  high  polish  is  given  to  the  entire  surface. 

In  manipulating  with  cohesive  foil,  a  preliminary  step  in  the  opera- 
tion is  to  attend  to  the  quality  of  the  gold.  It  must  possess  sufiicient 
adhesiveness  to  cohere  under  moderate  pressure ;  and  as  this  property 


480 


DENTAL  SURGERY. 


Fig.  296. 


deteriorates  on  the  exposure  of  the  foil  to  the  atmosphere,  it  is  often  neces- 
sary to  restore  it  by  the  application  of  heat,  as  the  welding  principle, 
and  not  mechanical  force,  is  relied  upon.  To  accomplish  this,  the  gold, 
either  in  the  sheet,  ribbon,  or  pellet  form,  is  subjected  to  the  flame  of 
an  alcohol  lamp  until  it  becomes  a  bright  red. 

Fig.  296  represents  a  Gold  Foil  Annealing  Lamp.  A  wire-gauze 
frame  is  very  convenient  for  re-annealing  the  entire  sheet,  and  a  mica 

plate  or  platinum  pan 
for  the  pieces  or  pellets. 
Many  prefer  to  pass  the 
roll  and  pellets  directly 
through  the  flame  at  the 
moment  they  are  being 
carried  to  the  cavity  with 
the  introducing  pliers. 
Another  method  is  to 
boil  the  gold  for  a  few 
minutes  in  a  solution 
composed  of  forty  drops 
of  sulphuric  acid  and  two 
gills  of  rain-water.  This 
diluted  acid  removes  all 
extraneous  matter  from 
the  surface  of  the  gold, 
which  soon  dries,  and  is 
found  to  be  very  cohesive. 
There  are  a  number  of 
methods  by  which  this 
form  of  gold  foil  is  prepared  for  introduction  into  the  cavity.  One 
consists  in  tearing  fragments  from  a  sheet  which  has  previously  been 
annealed,  and  condensing  a  single  thickness  at  a  time  with  a  fine 
serrated  point.  Another  method  consists  in  lightly  rolling  up  the 
whole  or  part  of  a  sheet  in  the  form  of  a  rope,  and  cutting  this  up 
into  pellets  of  different  sizes.  In  forming  the  pellets,  the  sheet  should 
be  very  lightly  rolled  up  between  the  thumb  and  fingers,  or,  what  is 
better,  lightly  folded  by  means  of  a  foil  folder  and  chamois  skin.  It 
may  also  be  folded  within  the  leaves  of  the  book  containing  it,  into 
two,  three,  four,  or  more  ribbons,  according  to  the  size  of  the  cavity 
to  be  filled,  and  then  cut  with  the  scissors. 

Fig.  297  represents  the  Foil  Clippers  for  cutting  ropes  of  gold  into 
small  pieces  or  pellets,  without  condensing  and  hardening  the  edges. 
Shears  and  scissors,  however  sharp,  will  condense  and  harden  the  gold, 
the  edsres  of  which  should  be  left  soft  and  free. 


COHESIVE   GOLD   FOIL.  48  X 

Some,  instead  of  forming  pellets,  prefer  to  introduce  this  quality  of 
gold  in  a  long  rope,  or,  better  still,  a  ribbon  containing  from  one-tenth 
to  one-half  sheet  of  No.  4  foil,  which  is  annealed  by  holding  it  in  the 
centre  with  the  pliers  and  rapidly  passing  it  through  the  flame.    When 

Fig.  297. 


the  gold  is  ready  to  introduce,  and  the  cavity  is  carefully  dried  and 
protected  against  moisture — absolute  dryness  being  very  essential  in 
the  use  of  all  the  cohesive  forms  of  gold — the  first  pellet,  or  the  end 
of  the  rope  or  ribbon,  when  this  form  is  used,  is  carried  from  the  flame 
31 


482  DENTAL   SURGERY. 

to  a  retaining  point  in  the  cavity,  where  it  is  securely  anchored  by 
being  thoroughly  consolidated  by  means  of  instruments  having  fine 
serrated  points.  As  soon  as  the  retaining  points  are  solidly  filled,  the 
gold  is  built  up  from  these  over  the  bottom  and  sides  of  the  cavity, 
care  being  taken  to  condense  it  well  against  the  walls  as  it  approaches 
the  orifice.  Every  pellet  or  fold  must  be  consolidated  as  il  is  intro- 
duced, and  the  gold  built  up  higher  against  the  walls  of  the  cavity 
than  in  the  centre,  until  the  orifice  is  reached,  when  the  depression 
left  in  the  centre  can  be  filled  up.  Very  lightly  rolled  or  folded  gold 
should  be  applied  to  the  walls  of  the  cavity,  else  it  may  clog,  and 
cannot  be  consolidated  to  such  a  degree  as  is  necessary  to  give  solidity 
to  the  filling.  It  is  beyond  question  that  to  the  introduction  of  the 
Rubber  Dam  is  due  the  splendid  achievements  with  cohesive  gold  of 
the  present  time,  as  it  is  absolutely  necessary  that  such  gold,  during 
its  manipulation,  should  be  kept  perfectly  dry.  The  Rubber  Dam  has, 
therefore,  become  an  indispensable  aid  in  all  manipulations  with  gold 
as  a  filling  material.  Should  moisture  interfere  with  the  introduction 
of  gold  in  filling  a  tooth,  it  is  far  preferable  to  remove  all  that  has 
been  introduced  and  commence  anew,  than  to  depend  upon  any  attempt 
to  dry  the  surface  by  means  of  heated  air  from  the  hot-air  syringe. 

Figs.  284,  286  and  287  (pages  469  and  470),  represent  the  forms  of 
instruments  for  introducing  and  consolidating  cohesive  gold  foil. 

Heavy  Foil. — A  number  of  years  ago,  attention  was  directed  by  Dr. 
Robert  Arthur  to  the  use  of  the  heavy  numbers  of  gold  foil  for 
filling  teeth ;  and  later  the  interest  in  this  form  of  gold  revived  to 
such  a  degree  that  very  many  advocated  its  claims. 

Nos.  15,  20,  30,  60,  120,  and  even  higher  numbers  have  been  used. 
Nos.  15  and  20  can  be  consolidated  by  hand  force,  if  such  is  desired, 
while  the  heavier  numbers  require  mallet  force.  The  method  of 
manipulating  this  foil  is  to  cut  it — without  allowing  it  to  come  in  con- 
tact with  the  fingers — into  pieces  varying  from  one-fourth  to  three- 
fourths  of  an  inch  square,  or  into  strips  of  a  proper  width  and  length  to 
suit  the  cavity  to  be  filled.  The  gold  is  then  annealed  by  heating 
each  piece  or  strip,  held  by  the  pliers  in  the  flame  of  an  alcohol  lamp, 
to  a  red  heat.  For  filling  the  front  teeth  the  strip  is  preferable, 
condensing  each  layer  across  the  entire  surface  of  the  cavity,  and 
folding  the  strip  upon  itself.  Retaining  points  are  solidly  filled,  and 
the  gold  built  from  one  to  the  other,  presenting  as  uniform  a  surface 
as  possible,  and  not  allowing  the  foil  to  become  crumpled  or  folded 
irregularly  upon  itself  For  filling  the  posterior  teeth  the  small  pieces 
are  prefei'able,  introduced,  like  the  strip,  with  the  pliers,  and  each  one 
thoroughly  consolidated.  The  gold  should  be  carefully  condensed  at 
and  over  the  margins  of  the  cavity,  layer  by  layer. 


CRYSTAL   OR  SPONGE   GOLD. 


483 


The  manufacture  of  these  heavy  foils  by  rolling,  instead  of 
beating  is  said  to  render  them  softer  and  more  adhesive  ;  but, 
in  the  editor's  opinion,  this  form  of  gold  offers  no  advantages 
over  the  lighter  numbers,  such  as  No.  4.  On  the  contrary,  it 
is  decidedly  more  difficult  of  manipulation,  and  far  less  easily 
adapted  to  the  walls  of  the  cavity.  Some  have  found  it  useful 
for  finishing  out  the  surfaces  of  large  fillings. 

Fig.  298  represents  a  set  of  Dr.  C.  R.  Butler's  instruments 
for  manipulating  the  heavy  foils  with  mallet  force. 

Fig.  298. 


CRYSTAL   OR   SPONGE   GOLD. 

In  the  use  of  crystal  or  sponge  gold,  a  different  method 
of  procedure  is  required  from  that  employed  with  foil. 

The  chief  difference  between  the  instruments  employed 
for  introducing  and  consolidating  crystal  gold  in  the  cavity 
of  a  tooth,  and  those  used  for  gold  foil,  consists  mainly  in 
having  the  working  extremity  blunt,  varying  in  diameter 
from  a  line  to  almost  a  mere  point,  with  shallow  serrations 
upon  the  surface. 

Fig.  299  represents  a  set  of  instruments  well  adapted  for 
the  manipulation  of  crystal  gold. 

In  filling  teeth  with  crystal  gold,  the  cavity  is  prepared  in 
the  same  manner  as  when  leaf  gold  is  employed.  This  done, 
the  gold  is  cut,  or  rather,  torn  from  the  block  with  the  point 
of  an  instrument,  into  small  pieces,  varying  in  size  according 
to  the  dimensions  of  the  cavity,  and  the  particular  stage  of 
the  operation  in  which  it  is  to  be  used.  It  being  important 
that  the  crystals  or  particles  composing  the  mass  should  be 
as  little  separated  or  displaced  as  possible  before  the  piece 


484 


DENTAL  SURGERY. 


is  carried  to  its  place  in  the  tooth,  this  form  of  gold  should  be  used  in 
pellets  as  large  as  can  be  introduced  into  the  cavity  without  crumbling. 
The  gold  being  divided  into  pieces  of  the  proper  size,  the  cavity  is 
Avashed,  and  then  wiped  dry  with  prepared  cotton,  or  flax  and  bibulous 
paper ;  a  piece  of  gold,  as  large  as  the  orifice  of  the  cavity  will  receive, 
is  taken  up  with  suitable  pliers,  or  one  of  the  sharp-pointed  instru- 
ments, as  may  be  most  convenient. 

Fig.  299. 


The  spongy  mass  readily  adheres  to  the  serrated  surface  of  the 
working  extremity,  when  pressed  gently  upon  it,  and  with  this  it  may 
in  most  cases,  be  carried  to  the  bottom  of  the  cavity.  Every  part 
must  now  be  thoroughly  consolidated,  first  with  a  large,  and  next  with 
a  smaller,  and  lastly  with  a  very  delicately-pointed  instrument,  so 
bent  that  it  may  be  readily  applied  to  all  the  depressions  and  inequali- 
ties of  the  walls  and  floor  of  the  cavity ;  for  unless  the  gold  is  made 
absolutely  solid  in  these  places,  as  well  as  throughout  all  the  parts  of 
the  filling,  the  success  of  the  operation  will  be  more  or  less  uncertain. 
Thus,  piece  after  piece  is  applied,  consolidating  each  one  as  the  opera- 
tion progresses,  until  the  gold  protrudes  suflficiently  from  the  orifice 
of  the  cavity  to  admit  of  a  good  finish,  leaving  the  surface  flush  with 
that  of  the  tooth. 

If,  during  any  part  of  the  operation,  the  smaller-pointed  instruments 
can  be  forced  between  the  gold  and  the  walls  of  the  cavity,  such  open- 
ing or  openings  should  be  filled  with  smaller  masses  of  the  material 
before  another  large  piece  is  introduced.  This  precaution  ought  never 
to  be  neglected ;  for  should  any  soft  places  exist  after  the  completion 
of  the  operation,  the  filling  will  be  apt  to  absorb  moisture,  and  ulti- 
mately to  crumble  and  come  out.  It  is  also  indispensably  necessary 
that  the  gold,  during  its  introduction  into  the  tooth,  be  kept  absolutely 
free  from  moisture,  as  this  destroys  the  cohesive  or  welding  property 
of  the  crystals. 


CRYSTAL   OR   SPONGE   GOLD. 


485 


The  gold  having  been  introduced  and  consolidated  as  directed,  the 
exposed  surface  is  scraped  or  filed  down  to  a  level  with  the  orifice  of 
the  cavity,  then  made  smooth  by  rubbing  it  with  Arkansas  stone  or 
with  finely-powdered  pumice,  and  burnished  or  polished  with  crocus, 
in  the  manner  as  described  when  gold  foil  is  used. 

In  finishing  a  filling  made  with  these  preparations  of  gold,  the  ope- 
rator should  see  that  there  are  no  thin,  overlapping  portions  upon  the 
teeth  outside  of  the  orifice  of  the  cavity.  They  are  liable,  in  biting 
hard  substances,  or  in  ordinary  mastication,  to  be  broken  off,  leaving 
a  depression  for  the  lodgment  of  extraneous  matter  and  clammy  secre- 
tions. Sooner  or  later  this  will  give  rise  to  a  softening  of  the  dentine 
thus  exposed,  which,  if  it  dose  not  cause  the  filling  to  loosen,  will  ulti- 
mately render  its  removal  and  replacement  necessary.  In  short,  the 
precautions  necessary  to  be  observed  in  making  a  filling  with  gold  foil 
are  equally  necessary  when  the  operation  is  made  with  either  of  the 
preparations  now  under  consideration. 

Mallet  Force  in  Consolidating  Gold. — A  number  of  years  ago  Dr.  W. 
H.  Atkinson  introduced  a  method  of  consolidating  gold  by  means  of 
mallet  force,  which  has  now  become  a  favorite  one  with  many  of  the 
best  operators  in  the  profession.  He  claimed  for  this  method  the  fol- 
lowing advantages  over  hand  pressure  :  A  more  perfect  condensation 
of  the  gold  and  a  more  thorough  welding  than  can  be  made  by  hand 
pressure ;  that  the  gold  will  be  anchored  in  its  position  with  much 
more  facility;  that  the  instrument  always  acts  under  the  mallet  upon 


the  designed  point,  does  not  slip  from  its  position, 
and,  consequently,  there  is  no  liability  of  abrad- 
ing or  wounding  the  soft  parts ;  that  mallet 
force  is  not  more  unpleasant  to  the  patient 
than  the  ordinary  method  of  condensing,  and 
that  it  is  far  less  fatiguing  than  hand  pressure 
in  protracted  operations. 

That  mallet  force  is  an  eflfective  method  of 
condensing  the  cohesive  forms  of  gold,  there 
can  be  no  question. 

Mallets  of  almost  every  description  are  used, 
such  as  wood,  lead,  tin,  copper,  brass,  steel, 
ivory  and  vulcanized  rubber. 

Heavy  lead  and  tin  mallets,  weighing  from 
four  and  a  half  to  six  and  a  half,  and  even 
eight  ounces,  are  preferred  by  many  of  the 
advocates  of  the  hand  mallet. 

In  using  the  hand  mallet,  which  is  repre- 
sented in  Fig.  300,  the  aid  of  an  assistant  is 


Fig.  300. 


486 


DENTAL.  SURGERY. 


Fig.  301 


Fig.  303. 


Fig.  304. 


Fig.  302. 


CEYSTAL   OR   SPONGE   GOLD,  487 

necessary,  who  taps  the  end  of  the  phigger  squarely  with  sharp, 
springing  strokes,  while  the  principal  operator  directs  its  condensing 
point  over  the  gold  as  it  is  introduced  into  the  cavity. 

With  instruments  called  automatic  mallet  pluggers — Fig.  301  repre- 
sents Snow  and  Lewis's;  Fig.  302,  Salmon's ;  Fig.  303, Taylor's — the  aid 
of  an  assistant  is  unnecessary. 

All  of  these  forms  operate  by  the  action  of  a  spiral  spring,  and  some 
of  them  have  a  back  action.  Taylor's  is  the  latest  form,  and  in  size 
and  action,  like  the  others,  is  a  valuable  instrument. 

Automatic  Pluggers  for  use  with  the  dental  engine  are  also  em- 
ployed for  the  condensation  of  gold  in  filling  teeth. 

Fig.  304  represents  the  invention  of  the  late  Dr.  T.  L.  Buckingham, 
which  was  one  of  the  first  of  these  appliances  brought  into  notice,  and 
which  has  given  satisfaction. 

The  force  of  the  blow  is  entirely  under  control,  being  determined  by 
the  set-screw  A,  which,  if  turned  to  the  right,  increases  the  force,  and 
if  turned  to  the  left  lessens  it.  The  force  can  also  be  kept  constantly 
under  control  by  the  collar  B,  on  the  hand-piece.  By  an  almost  auto- 
matic or  instinctive  movement  of  the  thumb  of  the  operator,  the  collar 
is  moved  up  or  down,  according  to  the  force  desired  in  the  blow. 

In  the  same  manner  the  blow  can  be  suspended  altogether,  at  any 
instant,  without  interfering  with  the  rhythmical  movement  of  the  foot 
propelling  the  engine,  as  when  picking  up  a  pellet  of  gold,  or  when  it 
is  desirable,  for  any  reason,  to  use  the  instrument  temporarily  as  a 
hand  plugger. 

The  force  and  effect  of  the  blow  may  also  be  accurately  regulated 
by  the  distance  at  which  the  point  is  held  from  the  filling,  being 
heavier  according  to  its  proximity  to  the  surface  to  be  condensed. 
Thus,  where  very  delicate  and  careful  manipulation  is  necessary,  as  at 
the  edges  of  a  cavity  in  a  frail  tooth,  the  operator  may  determine  the 
precise  force  by  the  distance  at  which  the  point  is  held. 

The  bit-holder  has  a  small  spiral  spring  at  its  inner  end,  which, 
after  each  blow,  draws  it  back  instantly  to  receive  the  next  blow  of 
the  plunger.  When  run  at  moderate  speed  this  plugger  will  give 
about  1800  blows  per  minute. 

Fig.  305  represents  an  Engine  Mallet  invented  by  Dr.  W.  C.  Bon- 

FiG.  305. 


488 


DENTAL  SURGERY^ 


will,  having  his  hand-piece  attached.  This  Engine  Mallet  gives  a 
very  satisfactory  blow,  and  requires  but  little  foot  power,  and  can  be 
worked  by  either  foot,  and  on  either  side  of  the  chair. 

Figs.  306  and  307  represent  Holmes's  Engine  Plugger,  and  also  a 
Right  Angle  Plugger  for  the  Dental  Engine,  which  are  neat  and 


Fig.  .306. 

mm 


Fig.  307. 


g--j^?vg.v!V».; 


iL;-^:'^^^^S.^<^^^ 


effective  devices,  and  of  small  size.  The  force  of  the  blow  is  regulated 
by  pressure  on  the  point,  and  pushing  forward  the  button  suspends 
the  blow. 

Figs.  308  and  309  represent  Acute  and  Obtuse  Angle  Engine  Plug- 

FiG.  308. 


Fig.  309. 


gers  for  use  upon  surfaces  where  the  direct  action  plugger  cannot  be 
readily  used  ;  such  as  posterior  approximal  surfaces. 

Fig.  310  represents  the  Electro-Magnetic  Mallet  invented  by  Dr. 
W.  G.  A.  Bonwill,  which  is  used  by  many  of  the  most  skillful  opera- 
tors.    Some  of  its  principal  advantages  are — 

First.  The  blow  is  delivered  upon  the  packing  instrument,  just  at 
the  point  where  its  force  is  greatest,  as  the  attraction  of  the  magnets 
constantly  increases  as  the  mallet  approaches  them,  until  the  circuit 
is  broken. 


CRYSTAL   OR  SPONGE   GOLD. 


489 


Fig.  310. 


Second.  The  force  of  the  blow  can  at  all 
times  be  controlled  by  the  operator. 

Third.  Properly  used  it  condenses  the 
gold  thoroughly  and  evenly  throughout  the 
entire  filling. 

Fourth.  Gold  may  be  impacted  against 
thin,  frail  walls  with  ease,  and  without  frac- 
turing the  enamel. 

Fifth.  It  saves  the  operator  time  and  the 
fatigue  attendant  upon  the  use  of  a  hand, 
automatic  or  foot-power  mallet. 

Sixth.  When  its  operation  is  understood, 
and  the  battery  is  kept  in  order,  as  per  in- 
structions, which  accompany  each  mallet 
sold,  the  instrument  does  not  require  any 
more  attention  than  the  care  of  a  watch. 

This  instrument  can  be  operated  by 
means  of  a  Bunsen  four-cell,  battery  (Fig. 
311) ;  the  fluids  for  which  are  the  bichro- 
mate of  potash  half  a  pound  dissolved  in 
half  a  gallon  of  warm  water,  and  ten  fluid 
ounces  of  sulphuric  acid  ;  this  solution  being 
placed  in  the  porous  cups.  For  making  the 
solution  which  surrounds  the  zinc,  one  part 
of  sulphuric  acid  to  ten  parts  of  water  are 
employed. 

Fig.  311. 


hJ^^ 


490 


DENTAL   SURGERY. 

Fig.  312. 


CRYSTAL   OR   SPONGE   GOLD. 


491 


Fig.  312  represents  a  set  of  instruments  F'c  314. 

devised  by  the  late  Dr.  Marshall  H.  Webb,         ^        /     f  . 
for  use  with  the  Electro-Magnetic  Mallet. 

Finishing  the  Surface  of  the  Filling. — After 
having  thoroughly  consolidated  the  surface 
of  the  filling,  finishing  files,  such  as  are 
represented  in  Fig.  313,  are  used  to  remove 
the  protruding  portions  of  gold,  and  to  form 
a  smooth,  uniform  surface,  free  from  the 
slightest  indentations  which  may  afford  lodg- 
ment to  extraneous  matter.  This  is  a  point 
never  to  be  lost  sight  of;  for,  however  excel- 
lent the  filling  may  be  in  other  respects,  if 
the  surface  is  not  smooth,  uniform,  and  flush 
with  the  orifice  of  the  cavity,  the  object  in- 
tended to  be  accomplished  by  it  will  be  par- 
tially, if  not  wholly,  defeated. 

It  is  better,  however,  to  cut  ofi"  but  a 
portion  of  the  protruding  gold  at  first,  and 
then  to  burnish,  condense  and  to  cut  a  second 
time,  with  a  fine  file  or  burr,  all  it  is  neces- 
sary to  remove.  After  each  filing,  and  before 
applying  the  burnisher,  the  surface  should 
be  cleansed  of  all  loose  pieces  of  gold.  After 
a  second  burnishing,  the  Arkansas,  Hin- 
dostan  or  Scotch  stone,  or  finely-powdered 
pumice  may  be  applied  to  the  surface,  to 
remove  all  the  file  scratches  and  other 
asperities.  For  a  filling  in  the  approximal 
surface  of  a  tooth,  the  stone  may  be  shaped 
like  a  pinion  file ;  it  should  be  frequently 
dipped  in  water,  and  when  its  pores  become 
filled  with  gold,  the  surface  may  be  ground 
oft"  by  rubbing  it  on  a  corundum  slab.  If 
the  filling  is  finished  with  pumice,  it  may  be 
applied  with  floss  silk  or  tape  moistened 
with  water,  by  drawing  it  backward  and 
forward  across  the  surface  of  the  filling. 

Fig.  814  represents  Cazier's  Plug-finish- 
ing Files,  for  finishing  contour  compound 
gold  operations  in  the  approximal  surfaces  of  bicuspids  and  molars,  and 
they  may  also  be  used  for  the  same  purpose  in  operations  on  the  cen- 
trals and  laterals.    With  them  the  gold  can  be  so  finished  as  to  restore 


492 


DENTAL   SUEGEEY. 


the  natural  contour,  thereby  preventing  the  surfaces  of  the  teeth  from 
assuming  an  unnatural  contact. 

Fig.  315  represents  different  forms  of  Plug-finishing  Burrs  for  use 
with  the  dental  engine. 

Fig.  315. 


Baehel. 


SUQAE  lOAP. 


KsTFF.  Edge. 


Fig.  316  represents  an  excellent  file-carrier,  contrived  by  Dr.  Forbes, 
for  files  for  finishing  fillings  on  the  approximal  surfaces  of  the  front 
teeth,  and  Fig.  317,  a  tape-carrier. 


Fig.  316. 


Fig.  317. 


CRYSTAL   OR   SPOXGE   GOLD. 


493 


If  the  filling  is  in  the  grinding,  buccal  or  palatine  surface  of  a 
molar  or  bicuspid,  a  long  piece  of  stone,  having  a  small,  triangular 
and  slightly  oval  point,  may  be  used ;  if  powdered  pumice-stone  be 
employed,  it  may  be  used  on  the  point  of  a  similarly  shaped  piece 
of  soft  wood,  previously  softened  in  water.  After  all  the  asperities 
have  been  cut  down,  the  surface  should  be  washed  until  every  particle 
of  grit  is  removed.  This  done  it  may  be  polished  with  a  suitable 
burnisher,  dipped  from  time  to  time  in  a  solution  of  pure  Castile  soap, 
until  the  filling  is  rendered  as  brilliant  as  a  mirror.  Fig.  318  repre- 
sents various  forms  of  burnishers. 

Fig.  318. 


Fig.    319  represents  a  set  of  burnishers  for  use  with  the   dental 

engine. 

Fig    319. 


Having  proceeded  thus  far,  the  surface  may  be  again  washed,  and 
the  operation  completed  by  rubbing  it  from  three  to  six  minutes  with 
dry  floss  silk.  Rouge  or  rotten  stone  applied  to  the  surface  on  tape,  or 
finely-powdered  silex  or  pumice-stone,  on  a  piece  of  orange-wood, 'after 
it  is  prepared  by  the  method  just  described,  will  remove  the  bright 
metallic  lustre — when  this  is  objectionable  on  account  of  the  exposure 
of  the  filling — and  leave  a  fine  finish.  Holly  strips  in  the  form  of 
thin  shavings,  anstver  admirably  for  applying  levigated  pumice,  rouge, 
etc.,  in  the  polishing  process. 

Non- Conductors. — When  the  caries    has   penetrated  nearly  to  the 


494  DENTAL   SURGERY. 

pulp  cavity,  the  presence  of  a  gold  or  any  other  metallic  filling  is 
sometimes  productive  of  considerable  pain  and  irritation,  especially 
when  hot  or  cold  fluids  are  taken  into  the  mouth,  or  during  the  inspi- 
ration of  cold  air.  In  some  cases,  inflammation  and  suppuration  of 
the  lining  membrane  and  pulp  supervene.  To  prevent  these  dis- 
agreeable results,  a  variety  of  means  have  been  proposed.  Dr. 
Solyman  Brown  recommended  placing  asbestos,  this  being  a  non-con- 
ductor of  caloric,  on  the  bottom  of  the  cavity  previously  to  the  intro- 
duction of  the  gold.  The  author  prefers  a  thin  layer  of  gutta  percha, 
which  may  be  used  in  the  form  of  a  thick  solution  prepared  with 
chloroform,  or  a  layer  of  thin  gutta-percha  cloth  may  be  placed  at 
once  in  the  bottom  of  the  cavity.  When  the  solution  is  used,  a  drop 
may  be  placed  in  the  cavity,  and  a  sufficient  time  allowed  for  the 
chloroform  to  evaporate,  before  introducing  the  filling.  A  thin  layer 
of  "  Hill's  stopping,"  of  which  gutta-percha  forms  the  principal  ingre- 
dient, may  be  used  with  equal  advantage.  Oxy chlorides  and  oxyphos- 
phates  of  zinc  have  also  been  used  for  the  same  purpose,  but  the  latter 
are  less  irritating  than  the  former,  and  neither  possess  any  advantages 
over  gutta-percha. 

The  time  required  by  an  expert  operator  to  fill  a  tooth  well  may  be 
said  to  vary  from  thirty  minutes  to  two  hours  and  a  half,  according  to 
the  size,  shape  and  situation  of  the  cavity,  and  in  some  cases  a  much 
longer  time  will  be  required.  The  author  has  found  it  necessary  in 
filling  some  cavities,  especially  when  the  restoration  of  a  large  portion 
of  the  crown  was  called  for,  to  bestow  as  many  as  six  hours'  constant 
labor  upon  the  operation.  Less  time  and  skill  are  usually  required  to 
fill  a  cavity  in  the  grinding  than  in  the  approximal  surface  of  a 
tooth  ;  but  the  operation  in  either  place,  to  be  beneficial  to  the  patient, 
must  be  performed  in  the  most  thorough  manner.  The  dentist  who 
does  not  feel  the  importance  of  making  all  his  operations  as  perfect  as 
possible,  should  never  be  intrusted  with  the  management  of  these  im- 
portant organs.  Want  of  attention  to  two  points  in  the  consolidation 
of  a  filling  often  causes  the  ultimate  failure  of  operations  in  all  other 
respects  well  performed.  First,  by  not  making  sufficient  lateral  com- 
pression whilst  introducing  the  gold,  the  surface  is  apt  to  be  more 
solid  than  the  interior.  Consequently  the  filling  may  drop  out  for 
want  of  a  firm  contact  against  the  sides ;  or,  if  retained,  it  is  apt  on 
grinding  surfaces  to  be  pressed  inward,  leaving  a  space  around  the 
orifice  for  the  penel^ration  of  fluids.  Second,  want  of  care  in  condens- 
ing around  the  edges  of  the  filling  will,  by  the  crumbling  away  or 
scaling  off*  of  portions  of  the  gold,  expose  the  edges  of  the  cavity  to 
decay. 

In  every  part  of  the  operation,  the  dentist  should  so  guard  his  in- 


FILLING   INDIVIDUAL   CAVITIES   IN   TEETH.  495 

struments  as  to  prevent  them  from  slipping,  which  he  will  usually  be 
better  able  to  do  by  standing  a  little  to  the  right  and  behind  his 
patient  than  in  any  other  position.  In  filling  the  lower  teeth  he  should 
stand  several  inches  higher  than  Avhile  filling  the  upper,  and  for  this 
purpose  he  should  have  a  stool  or  movable  platform  on  which  to 
stand.  When  it  can  be  done,  he  should  grasp  the  tooth  with  the 
thumb  and  forefinger  of  his  left  hand,  not  only  to  prevent  it  from 
being  moved  by  the  pressure  he  applies,  but  also  to  catch  the  point  of 
the  instrument  in  case  it  should  slip;  if  he  is  always  careful  to  press 
in  a  direction  toward  the  orifice  of  the  cavity,  this  need  not  happen  ; 
nevertheless,  he  should  always  take  the  precaution  to  guard  against 
possible  accident.  When  he  cannot  shield  the  mouth  with  the  thumb 
and  finger  of  his  left  hand,  he  should  let  the  thumb  or  one  of  the 
fingers  of  his  right  rest  either  upon  the  tooth  he  is  operating  on  or 
upon  some  other. 

For  the  special  application  and  modification  of  these  general  direc- 
tions, the  reader  is  referred  to  the  filling  of  individual  cavities  in 
teeth. 

FILLING   INDIVIDUAL   CAVITIES   IN   TEETH. 

To  describe  the  method  of  filling  each  individual  cavity  in  every 
locality  in  which  a  tooth  is  liable  to  be  attacked  by  caries  would  be 
unnecessarily  tedious.  But,  as  this  is  one  of  the  most  important,  and, 
at  the  same  time,  one  of  the  most  difficult  operations  in  dental  surgery, 
it  may  be  well  to  enter  a  little  more  into  detail  upon  the  subject  than 
we  have  as  yet  done.  In  doing  this,  the  writer  will  confine  himself, 
for  the  most  part,  to  the  manner  of  filling  a  cavity  in  each  of  the  fol- 
lowing localities,  which  are  the  parts  of  teeth  most  liable  to  caries. 

First.  In  the  approximal  and  labial  surfaces  of  the  superior  incisors 
and  cuspids,  and  the  palatine  surfaces  of  the  incisors ;  the  anterior 
surfaces  of  the  cuspids  and  the  posterior  surfaces  of  cuspids  and  in- 
cisors being  rarely  attacked  by  caries. 

Second.  In  the  grinding,  approximal,  buccal  and  palatine  surfaces 
of  the  molars  and  bicuspids  of  the  upper  jaw. 

Third.  In  the  approximal  surfaces  of  the  inferior  incisors  and  cus- 
pids. 

Fourth.  In  the  grinding,  approximal,  and  buccal  surfaces  of  the 
molars  and  bicuspids  of  the  lower  jaw. 

Other  parts  of  the  teeth  sometimes  become  the  seat  of  caries,  but 
the  foregoing  are  the  localities  most  liable  to  be  attacked  by  the 
disease. 


496  DENTAL  SUEGERY. 

FILLING  THE  SUPERIOR  INCISORS  AND  CUSPIDS. 

I.  With  Non-cohesive  Gold  Foil. — In  describing  the  manner  of  intro- 
ducing a  filling  in  one  of  the  first-named  teeth,  we  shall  commence  with 
the  right  approximal  surface  of  the  left  central  incisor.  The  direc- 
tions we  propose  giving  for  the  performance  of  the  operation  here,  will 
be  applicable,  with  a  few  exceptions,  to  the  same  surface,  on  all  the 
upper  incisors.  As  a  general  rule,  the  gold  should  be  introduced  from 
behind  the  teeth  forward  and  upward,  and  for  the  following  reasons : 
1.  When  the  aperture  between  the  teeth  has  been  formed  with  a  file, 
it  should,  when  the  circumstances  of  the  case  will  permit,  and  for 
reasons  stated  in  another  place,  be  made  wider  behind  than  before  ; 
consequently,  the  diseased  part  can  be  most  easily  approached  from 
this  direction.  2.  The  gold,  in  the  majority  of  cases,  can  be  more 
conveniently  introduced  from  the  palatine  side,  and  the  force  required 
for  condensing  it  can  be  more  advantageously  applied. 

The  exceptions  to  the  above  rule  are,  when  the  approximal  side  of 
the  tooth  is  turned  slightly  forward  toward  the  lip,  and  when  the  caries 
is  situated  nearer  the  labial  than  the  palatine  angle ;  also,  when  the 
teeth,  instead  of  occupying  a  vertical  position  in  the  alveolar  border, 
or  projecting  slightly,  as  they  usually  do,  incline  backward  toward  the 
roof  of  the  mouth.  It  sometimes  happens,  too,  when  they  are  sepa- 
rated by  pressure,  that  the  diseased  part  can  be  most  conveniently 
reached  from  before. 

The  instrument  which  the  author  has  found  best  adapted  for  the 
introduction  of  the  gold  into  a  cavity  in  the  right  approximal  surface 
of  an  incisor  or  cuspid  tooth  is  represented  in  Fig.  320.     The  width 

Fig.  320. 


and  length,  as  well  as  the  curvature  or  angle  of  the  point,  should  vary 
according  to  the  size  of  the  cavity  and  the  width  of  the  space  between 
the  teeth. 

The  stem  of  the  instrument  as  well  as  the  shank  should  be  strong 
Fig.  321.  enough  to  sustain  any  amount 

of  pressure  which  it  may  be 
necessary  to  apply  in  forcing 
the  folds  of  gold  tightly  against 
each  other.  The  point  should 
be  wedge  shape,  and  the  extremity  serrated. 

The    decay   having   been    removed,  the   cavity,  properly  shaped, 


FILLING   THE   SUPERIOR   INCISORS    AND   CUSPIDS. 


497 


cleansed,  dried  and  protected,  is  ready  for  the  reception  of  the  gold. 
The  patient  should  be  seated  in  a  chair  sufficiently  high  to  bring  the 
head  on  a  level  with  the  breast  of  the  operator,  and  resting  on  the 
head-piece  of  the  chair,  with  the  face  upward.  The  operator,  standing 
upon  the  right  side,  should  support  the  patient's  head  firmly  with  his 
left  arm  during  the  operation,  while  with  the  forefinger  of  the  same 
hand  the  upper  lip  is  held  out  of  the  way.  The  middle  finger  of  the 
same  hand  ought  to  rest  on  the  end  of  a  tooth  to  the  left  of  the  one  on 
which  the  operation  is  being  performed,  while  with  the  little  finger  the 
lower  lip  may  be  gently  depressed.  The  roll  or  strip  of  gold  is  first 
introduced  with  the  foil  pliers. 

During  the  introduction  of  the  gold,  the  instrument  should  be  held 
in  the  right  hand  of  the  operator  (Fig.  322),  and  grasped  with  sufficient 
firmness  to  prevent  it  from  slipping  or  rotating. 

In  introducing  the  gold,  the  first  fold  should  be  applied  against  the 
upper  wall  of  the  cavity, 

that  the  pressure  may  al-  ^^^'  ^'^'^■ 

ways  be  exerted  in  a  di- 
rection toward  the  extrem- 
ity of  the  root,  applying 
each  additional  fold  as 
closely  to  the  preceding 
one  as  possible.  The  folds 
should  also,  in  their  intro- 
duction, be  applied  as 
closely  to  the  labial  and 

palatine  walls  of  the  cavity  as  possible,  but  always  directing  the  pres- 
sure, when  these  are  thin  and  brittle,  in  the  direction  of  the  axis  of  the 
root. 

When  the  low^er  part  of  the  cavity  is  very  narrow,  as  is  often  the 
case,  especially  where  it  extends  nearly  to  the  labial  angle  of  the 
tooth,  it  is  often  necessary  to  change  the  instrument  for  one  having  a 
smaller  point. 

To  carry  a  fi)ld  of  gold  to  the  bottom  of  a  cavity  upon  the  point 
of  the  instrument,  without  breaking  or  cutting  it,  requires  some  tact. 
The  point  should  never  be  carried  directly  toward  the  bottom  ;  on 
entering  the  orifice,  it  should  be  inclined  toward  the  wall  of  the  cavity 
opposite  the  one  against  which  the  folds  are  first  laid.  Equally  as 
much  tact  is  required  to  prevent  displacing  the  gold  before  a  sufficient 
quantity  has  been  introduced  to  procure  support  for  it  from  the  sur- 
rounding walls,  which  is  an  accident  particularly  apt  to  occur  with 
young  practitioners,  when  the  cavity  is  superficial  and  has  a  large 
orifice.  To  prevent  this,  the  folds  of  gold  should  be  long  enough  to 
32 


la,     .;>^^. 


498  DENTAL  SURGERY. 

project  some  distance  from  the  orifice,  that  they  may  receive  support 
from  the  adjoining  tooth,  and  from  the  thumb  and  forefinger  of  the 
left  hand  of  the  operator,  until  the  operation  has  reached  that  stage 
when  sufficient  stability  shall  have  been  obtained  from  the  walls  of 
the  cavity. 

There  are  cases  in  which  an  instrument  like  the  one  represented  in 
Fig.  323  can  be  very  advantageously  employed 
in  the  introduction  of  the  gold  ;    but  in  the 
rii^^^'^r^^^sj^^^^—      majority  of  cases  the  instrument  represented 
in  Fig.  320  will  be  found  more  convenient. 
After  having  filled  the  cavity  so  thoroughly  that  a  small  wedge- 
pointed  instrument  cannot  be  made  to  penetrate  the  gold  at  any  point, 
the  extruding  portion  of  the  filling  should  be  consolidated  ;  beginning 
with  the  portions  overlapping  the  lower  part  of  the  tooth  and  the  edge 
of  the  posterior  wall.     These  should  be  carefully  and  firmly  pressed 
toward  the  cavity,  with  an  instrument  having  a  flat  point,  like  the  one 
represented  in  Fig.  324.     This  done,  it  may  be  firmly  applied  to  every 
part  of  the  surface  of  the  filling,  continuing  the  pressure  as  long*  as 
the  point  of  the  instrument  can  be  made  to  indent  the  gold. 

When  the  space  between  the  teeth  is  very  narrow,  an  instrument 
shaped  as  in  Fig.  325  may  be  used.  The  operator  should  be  provided 
with  two  or  three  instruments  like  each  of  the  two  last,  varying  in  the 
size,  length  and  curvature  of  their  points. 

During  the  process  of  consolidating  the  gold,  the  tooth  should  be 
firmly  grasped  between  the  thumb  and  forefinger  of  the  left  hand  ; 
this  prevents  it  from  being  pressed  too  forcibly  against  the  opposite 
side  of  the  socket,  while,  at  the  same  time,  the  end  of  the  forefinger, 
by  being  placed  above  the  instrument,  assists  in  directing  its  point,  and 
serves  to  keep  it  from  slipping.  When  the  labial  and  palatine  walls 
of  the  cavity  are  very  thin,  great  care  is  necessary  to  prevent  fractur- 


FiG.  324.  Fig.  325.  Fig.  326 


ing  them  in  introducing  and  consolidating  the  gold.  The  consolida- 
tion should  be  commenced  around  the  edges,  and  the  pressure  applied 
toward  the  centre  of  the  cavity. 

It  sometimes  happens  that  the  caries  extends  forward  to  the  labial 
angle  of  the  tooth,  and  upward,  at  the  same  time,  under  the  edge  of 
the  gum.  Great  difficulty  is  often  felt  in  thoroughly  filling  this  por- 
tion of  the  cavity,  and  it  cannot  always  be  done  from  behind  the  tooth. 
In  this  case,  after  having  filled  the  cavity  in  the  manner  as  already 


FILLING  THE   SUPERIOR   INCISORS   AND   CUSPIDS. 


499 


Fig.  327. 


described,  the  operator  may,  standing  on  the  left  side  of  the  patient, 
and  with  an  instrument  having  a  wedge-shaped  point  (Fig.  326),  make 
as  large  an  opening 
as  possible  in  the 
gold.  This  done, 
he  may  grasp  the 
left  lateral  incisor 
or  cuspid  tooth 
with  the  thumb 
and  middle  finger 
of  his  left  hand, 
elevating  the  upper 
lip  with  the  fore- 
finger of  the  same ; 

then,  with  the  instrument  held  as  in  Fig.  327,  he  may  proceed  to  in- 
troduce the  gold,  filling  the  upper  part  of  the  opening  first.  After 
introducing  fold  after  fold,  until  it  is  completely  and  compactly  filled, 
the  extruding  portion  should  be  consolidated  wuth  a  similarly-shaped 
instrument,  having  a  flat,  serrated  point,  this  style  of  point  being 
preferable  to  the  round  point  for  introducing  and  consolidating  non- 
cohesive  gold. 

The  size  of  the  roll  of  gold  must  be  varied  to  suit  the  size  of  the 
cavity,  though  it  should  seldom  have  in  it  more  than  a  fourth  of  a 
leaf  of  No.  4.  If  more  than  this  be  employed  at  one  time,  it  will  be 
difficult  to  apply  the  folds  sufiiciently  near  each  other. 

The  method  of  filling  the  right  central  incisor  in  the  left  approximal 
surface  is  so  very  similar  to  that  of  filling  the  left  in  the  right  side, 
that  it  will  not  be  necessary  to  enter  so  minutely  into  detail.  In  this 
as  in  the  other  case,  the  gold,  as  a  general  rule,  should  be  introduced 
from  behind  the  tooth,  forward  and  upward  ;  but  if  introduced  from 
the  front,  the  operator  should  still  stand  on  the  right  side  of  the 
patient.  The  head  should  have  the  same  elevation,  and  inclination 
backward ;  but  the  face  should  be  turned  more  toward  the  operator,  to 
give  him  a  better  view  of  the  cavity  in  the  tooth,  and  to  enable  him  to 
reach  it  more  readily  with  the  instrument. 

The  cavity  being  formed,  cleansed  and  dried,  the  operator  may  pro- 
ceed to  introduce  the  gold,  as  already  directed,  with  an  instrument  like 
the  one  represented  in  Fig.  320.  In  many  cases,  however,  he  will 
require  one  having  a  somewhat  longer  point,  and  curved  at  nearly  a 
right  angle  with  the  stem.  The  instrument  should  be  held  some- 
what differently  in  the  hand  (Fig.  328),  and  grasped  firmly  with  the 
thumb  and  fore  and  middle  finger,  so  as  to  prevent  it  from  rotating. 
The  head  should  be  securely  confined  with  the  left  arm,  the  upper  lip 


500 


DENTAL  SURGEEY. 


»^|5$g 


Fig.  328.  raised   with    the    left 

thumb,  pressing  it  at 
the  same  time  firmly 
against  the  anterior 
surface  of  the  tooth. 
The  middle  or  fore 
finger  of  the  same 
hand  may  be  placed 
against  the  gum  just 
inside  the  tooth,  to  di- 
rect the  application  of  the  point  of  the  instrument,  prevent  the  liability 
of  its  slipping,  and  control  the  free  end  of  the  roll  of  foil.  The  lower 
lip  may  be  depressed  either  with  the  middle  joint  of  this,  or  with  one 
of  the  other  fingers. 

After  having  placed  one  end  of  the  gold  in  the  cavity,  fold  after 
fold  should  be  introduced  until  it  is  compactly  filled  ;  except  in  those 
cases  where  the  lower  part  is  very  small,  when  a  smaller-pointed  instru- 
ment should  be  employed  for  the  completion  of  the  operation,  and, 
indeed,  for  the  introduction  of  all  the  gold,  if  the  cavity  is  not  large, 
or  the  aperture  between  the  teeth  very  narrow. 

For  consolidating  the  extruding  gold,  the  instrument  represented  in 
Fig.  324  will,  in  many  cases,  be  all  that  is  required.  But  the  one 
represented  in  Fig.  329  can  sometimes  be  used  very  advantageously ; 


Fig.  329. 


Fig.  330. 


and  the  one  in  Fig.  330  will  be  found  a  useful  condenser  for  the  right 
as  well  as  the  left  approximal  surface  of  an  incisor  or  cuspid  tooth  ; 
and  both  the  last  mentioned  instruments  may  often  be  used  to  great 
advantage  on  the  approximal  surfaces  of  other  teeth.  Some  of  the 
instruments  employed  in  filling  teeth  with  adhesive  and  crystal  or 
sponge  gold  may  also  be  advantageously  employed  in  consolidating 
the  ordinary  gold  in  the  approximal  surfaces  of  the  incisors  and  other 
teeth. 

In  completing  the  operation,  it  is  important  that  every  particle  of 
gold  overlapping  the  orifice,  and  frequently  extending  under  the  free 
edge  of  the  gum,  should  be  removed  before  finishing  the  surface  of 
the  filling ;  but  the  operator  ought,  at  the  same  time,  to  avoid  as  much 
as  possible  wounding  the  gum  and  dental  periosteum.  As  the  cavity 
frequently  extends  a  little  above  the  gum,  great  care  is  necessary  to 
prevent  wounding  it ;  indeed,  there  are  many  cases  in  which  it  cannot 


FILLING   THE   SUPERIOR   INCISORS   AND   CUSPIDS. 


501 


be  avoided,  unless  the  point  of  the  gum  is  pressed  up  between  the 
teeth,  by  the  introduction  of  a  piece  of  raw  cotton,  band  of  rubber  or 
Avedge  of  wood,  a  day  or  two  before  the  operation  of  filling  is  per- 
formed. 

In  filling  an  incisor  or  cuspid  tooth  on  the  labial  surface,  the  opera- 
tion is  often  very  simple  and  easy ;  but  there  are  many  cases  in  which 
it  is  both  difficult  and  tedious.  The  head  of  the  patient  should  rest 
with  the  face  upward,  as  already  described,  and  sustained  in  the  same 
way  with  the  left  arm  of  the  operator,  while,  with  the  thumb  of  the 
left  hand  placed  on  the  gum  above  the  tooth,  the  upper  lip  should  be 
elevated. 

The  forefinger  should  be  pressed  firmly  against  the  palatine  surface 
of  the  tooth,  and  the  left  side  of  the  chin  gently  grasped  with  the 
other   thi'ee   fingers.      Then,    with    an   instru- 
ment (Fig.  331)  having  a  wedge-shaped  point,  Fig.  33L 
grasped  with  the  right  hand,  as  in  Fig.  328 
or  332,  the  operator  should  proceed  to  intro- 
duce the  gold,  standing  at  the  right  side  of  the 

patient,  with  the  thumb  of  the  right  hand  resting  on  a  tooth  to  the 
left  of  the  one  he  is  about  to  fill,  or  against  the  cheek.  He  should 
commence  by  laying  the  first  fold  against  the  walls  of  the  cavity  nearest 
to  him,  and  thus  introduce  fold  after  fold,  until  it  is  compactly  filled. 


Fig.  332 


^^,,^|;«A 


^^jj^^-^^^^^^^^liiliiiiiii^^lll;  yy 


The  extruding  portion  may  be  consolidated  with  a  round  or  square- 
pointed  instrument,  or  with  a  sharp-pointed  one,  as  represented  in 
Fig.  333.  Great  care  is  necessary  to  prevent  the  instrument  from 
slij^ping  and  wounding  the  gums.  After  having  partially  consolidated 
the  gold,  the  overlapping  portion  must  be  firmly  pressed  toward  the 
centre  of  the  cavity,  and  the  point  of  the  instru- 
ment repeatedly  applied  to  every  part  of  the 
surface  of  the  filling,  until  it  can  no  longer  be 
made  to  yield  to  pressure.    This  done,  the  gold 


Fig.  333. 


502  DENTAL   SURGERY. 

may  be  filed  down  to  the  level  of  the  tooth,  smoothed  with  Arkansas 
stone,  and  burnished  or  polished. 

When  the  cavity  is  shallow  and  the  orifice  broad,  the  gold,  as  it  is 
introduced,  must  be  held  in  its  place  with  the  thumb  of  the  left  hand, 
until  a  sufficient  quantity  has  been  placed  in  the  cavity  to  obtain  for 
it  the  necessary  support  from  the  surrounding  walls.  But  in  over- 
coming difficulties  of  this  sort,  the  peculiar  circumstances  of  the  case 
can  alone  suggest  the  proper  means  to  be  employed  by  the  operator. 

The  decay  sometimes  extends  entirely  across  the  labial  surface  of 
the  tooth,  leaving  after  its  removal  a  horizontal  groove  open  at  both 
ends.  In  this  case  the  walls  should  be  made  rough,  wider  at  the  bot- 
tom than  at  the  opening,  and  the  operation  of  filling  commenced  at  one 
end,  by  applying  the  folds  of  foil  alternately  against  the  upper  and 
.lower  wall,  and  consolidating  them  so  thoroughly  as  to  prevent  the 
liability  of  their  being  displaced  during  any  subsequent  part  of  the 
operation.  Successive  folds  are  introduced  in  the  same  manner,  each 
in  close  contact  with  the  preceding  series,  until  the  groove  is  completely 
filled,  applying  the  pressure,  during  the  whole  of  the  operation,  against 
the  two  walls.  In  condensing  the  extruding  gold,  the  operator  should 
commence  first  at  one  end  of  the  groove,  then  at  the  other,  and  after- 
ward consolidate  the  whole  surface  of  the  filling.  In  finishing  the 
operation,  the  same  precaution,  with  regard  to  wounding  the  gum  and 
dental  periosteum,  should  be  observed  here  as  recommended  for  the 
approximal  surface  of  the  tooth. 

Although  it  rarely  happens  that  the  palatine  surfaces  of  the  upper 
incisors  are  attacked  by  caries,  yet  the  disease  does  sometimes  develop 
itself  there,  in  the  indentations  occasionally  found  a  little  below  the 
free  edge  of  the  gum.  The  removal  of  the  diseased  part,  the  forma- 
tion of  a  cavity,  and  the  introduction  of  a  filling,  can,  in  the  majority 
of  cases,  be  more  easily  accomplished  in  this  than  in  any  other  part 
of  an  incisor  tooth. 

Fig.  334.  Fig.  335. 


The  cavity  being  properly  prepared  for  filling,  the  head  should  be 
placed  as  before  directed,  except  that  the  chin  may  be  a  little  more 
elevated,  to  enable  the  operator  to  obtain  a  more  convenient  view  of 
the  locality  of  his  operation  ;  the  thumb  of  the  left  hand  may  be  placed 
on  the  labial  surface  of  the  tooth ;  and  the  forefinger  on  the  gum 
immediately  above  the  palatine  surface.  He  should  now,  with  a 
wedge-pointed  instrument,  shaped  as  in  Fig.  334,  proceed  to  introduce 


FILLING   THE  SUPERIOR   INCISORS   AND   CUSPIDS.  503 

the  gold,  applying  the  iirst  fold  against  the  palatine  wall  or  the  palato- 
approximal  angle  of  the  cavity,  as  may  be  most  convenient.  Having 
filled  the  cavity,  the  extruding  gold  may  be  condensed  with  an  instru- 
ment like  the  one  represented  in  Fig.  335. 

Sometimes  straight  instruments,  and  at  other  times  instruments 
curved  at  the  points  more  than  those  represented  in  Figs.  334  and  335, 
can  be  more  conveniently  employed  ;  depending  altogether  upon  the 
size  of  the  mouth,  and  the  forward  or  backward  deviation  of  the  teeth 
from  a  vertical  position.  This  is  a  matter,  therefore,  which  the  judg- 
ment of  the  operator  must  determine. 

II.  With  Cohesive  Gold  Foil. — For  filling  cavities  in  the  approxi- 
mal  surfaces  of  the  superior  incisors  and  cuspidati,  the  most  effectual 
means  should  be  adopted  to  retain  the  filling.  In  some  few  cases  it 
may  not  be  possible  to  do  more  than  form  small  under-cuttings  at  each 
approximal  angle  of  the  cavity,  and  another  similar  one  at  the  cutting 
edge,  which  would  be  sufficient  for  the  retention  of  a  non-cohesive  gold 
filling ;  but  in  the  majority  of  cases,  one  of  cohesive  gold  can  be  so 
securely  anchored  that  the  cervical  wall  is  perfectly  protected,  and  a 
fracture  at  any  point  along  the  edges  of  the  cavity  will  not  dislodge 
the  filling. 

To  effect  this,  retaining  points  made  by  a  small,  square-edged  drill, 
are  necessary,  which  can  be  formed  in  approximal  surface  cavities 
of  the  incisors  and  cuspidati,  in  that  portion  of  the  dentine  near  the 
labial  surface  where  it  unites  with  the  cementum,  and  in  the  same  posi- 
tion in  the-  palatine  surface.  These  retaining  points  can  be  made  from 
the  one-twentieth  to  the  one-sixteenth  of  an  inch  in  depth,  and  in  addi- 
tion a  small  undercutting  on  the  wall  next  to  the  cutting  edge.  In 
drilling  the  retaining  points  in  the  cervical  wall  near  the  labial  and 
palatine  surfaces,  the  drill  should  be  directed  in  a  line  with  the  long 
axis  of  the  root,  in  order  that  the  cavity  made  by  it  is  sufficiently  dis- 
tant from  the  pulp  of  the  tooth.  The  cavity  being  properly  formed, 
dried,  and  protected  from  all  moisture,  the  gold  foil,  prepared  in  the 
manner  before  described,  is  carried  into  the  cavity  with  the  introducing 
pliers,  or  on  the  point  of  an  instrument,  and  packed  into  the  retaining 
points  until  these  are  solidly  filled. 

The  gold  is  then  compactly  built  from  one  of  these  retaining  points 
to  the  other,  and  over  the  floor  of  the  cavity,  until  a  base  is  formed 
extending  over  the  whole  of  the  floor. 

From  this  base  the  gold  is  then  built  to  the  orifice ;  and  during  the 
entire  process,  it  is  packed  a  little  higher  about  the  walls  than  in  the 
centre,  in  order  to  obtain  a  more  'thorough  contact.  When  the  gold 
has  reached  the  orifice,  the  centre  is  then  built  up,  and  the  surface  con- 
densed and  finished  as  before  described. 


504  DENTAL  SURGERY. 

Crystal  gold  is  preferred  by  some  for  filling  the  retaining  points 
and  forming  the  base  covering  the  floor  of  the  cavity,  on  account  of  its 
retaining  its  position  better  than  foil.  This  description  of  the  method 
of  introducing  cohesive  foil  will  apply  to  all  cavities  wherever  situated, 
and  need  not  be  repeated  hereafter.  For  crystal  gold  the  cavity  may 
be  formed  in  the  same  manner  as  for  cohesive  gold  foil,  although  many 
depend  upon  under-cuttings  instead  of  retaining  points,  for  its  retention. 

As  the  method  of  introducing  crystal  gold  into  cavities  has  already 
been  described,  it  is  not  necessary  to  say  more  concerning  it. 

FILLING   THE   SUPERIOR   MOLARS   AND   BICUSPIDS. 

1.  With  Non- cohesive  Gold  Foil. — In  describing  the  manner  of 
filling  a  cavity  in  each  of  the  principal  localities  liable  to  be  attacked 
by  caries  in  the  above-mentioned  teeth,  the  writer  will  begin  with  the 
grinding  surface  of  the  first  molar  on  the  right  side.  The  directions 
given  for  filling  a  cavity  here,  will,  with  a  few  exceptions,  be  applicable 
to  the  introduction  of  a  filling  in  the  grinding  surface  of  any  of  the 
upper  molars  or  bicuspids. 

When  the  cavity  is  very  deep,  and  its  circumference  not  large,  it  is 
difficult,  if  not  impossible,  to  make  a  filling  sufficiently  firm  and  solid 
in  every  part,  by  the  introduction  of  folds  of  gold  long  enough  to 
extend  from  the  bottom  to  the  orifice.  The  operation,  therefore,  should 
be  divided  into  two  parts;  two-thirds  of  the  cavity  should  be  first 
thoroughly  filled  with  vertical  folds,  and  afterward  the  remaining  third 
in  the  same  manner. 

In  filling  a  molar  or  bicuspid  on  any  of  its  surfaces,  the  head  of  the 
patient  should,  for  the  most  part,  occupy  very  nearly  the  same  position, 
and  have  the  same  elevation  as  required  for  an  operation  on  an  incisor 
or  cuspid.  The  cavity  being  prepared  for  the  filling,  and  one  end  of 
the  roll  or  ribbon  of  foil  placed  in  it,  the  tooth  may  be  grasped  with 
the  thumb  and  forefinger  of  the  left  hand  of  the  operator — the  former 
placed  on  the  buccal  surface  in  such  a  manner  as  to  press  back  the 
commissure  of  the  lips,  and  the  latter  on  the  palatine  surface ;  then  fold 
after  fold  may  be  introduced  and  forcibly  pressed  against  the  posterior 
wall  until  the  cavity  is  filled.  For  this  purpose  an  instrument  may  be 
used  like  the  one  represented  in  Fig.  331  or  334.  If  the  former  is 
used,  it  is  to  be  held  as  shown  in  Fig.  328.  The  extruding  portion 
should  then  be  condensed  with  the  same  instrument  as  the  one  used  for 
introducing,  and  still  more  condensed,  if  necessary,  with  pluggers  simi- 
lar to  Figs.  335  and  336. 

As  a  general  rule,  filling  a  cavity  in  the  grinding  surface  of  an  upper 
molar  or  bicuspid  is  an  exceedingly  simple  opei'ation,  requiring  less 
skill  than  the  introduction  of  a  plug  in  any  other  locality  in  these  teeth  ; 


FILLING   THE   SUPERIOR   MOLARS   AND   BICUSPIDS.  505 

but  there  are  cases  in  which  it  is  rendered  very  difficult,  as,  for  example, 
when  there  are  one  or  more  fissures  or  carious  depressions  radiating 
from  the  main  cavity.  After  the  caries  has  been  removed  and  the 
fissure  enlarged,  which  was  often  a  very  tedious  operation  before  the 
use  of  fissure  burrs  with  the  dental  engine,  it  requires  considerable  time 
and  skill  to  fill  these  thoroughly.  When  it  is  not  properly  done,  as  is 
too  often  the  case,  a  recurrence  of  the  disease  will  soon  take  place, 
and  thus  defeat  the  object  for  which  the  operation  was  performed. 

The  introduction  of  a  filling  in  the  grinding  surface  of  the  second 
or  third  molar  of  a  person  having  a  very  small  mouth  is  sometimes 
attended  with  great  difficulty ;  in  some  cases  it  can  only  be  done  with 
an  instrument  having  a  point  bent  nearly  at 
right  angles  with  the  stem,  like  the  one  repre-  ^  -^^^^ 
sented  in  Fig.  336 ;  consequently,  the  power  re- 
quired for  introducing  and  consolidating  the  gold 
is. applied  to  great  disadvantage.  But  the  instru- 
ment represented  in  this  cut  is  only  intended  for 
the  first  part  of  the  operation  of  consolidating 
the  metal ;  for  its  completion  smaller  points  are  required. 

In  filling  a  cavity  in  the  grinding  surface  of  a  first  upper  molar  on 
the  left  side  of  the  mouth,  the  thumb  of  the  left  hand  may  be  placed 
against  the  left  cuspid  or  first  or  second  bicuspid,  as  may  be  most  con- 
venient to  the  operator,  while  the  forefinger  is  placed  behind  the  point 
of  the  instrument,  and  at  the  same  time  made  to  push  back  the  com- 
missure of  the  lips.  To  obtain  a  good  view  of  the  cavity  in  a  second 
or  third  molar  during  the  operation,  the  cheek  should  be  pressed  from 
the  tooth  with  the  forefinger  of  the  left  hand ;  but  this  finger  can 
seldom  be  carried  far  enough  back  on  this  side  of  the  mouth  to  be 
placed  behind  the  point  of  the  instrument.  During  the  introduction 
of  gold  the  instrument  should  be  grasped  as  in  Fig.  328,  or,  better  still, 
as  in  Fig.  332. 

In  filling  a  cavity  in  the  anterior  approximal  surface  of  a  right 
superior  molar  or  bicuspid,  the  operation  may  be  commenced  by 
placing  the  gold  against  the  palatine  wall,  and  ending  at  the  buccal. 
But  before  the  process  of  condensing  is  commenced,  every  portion  of 
the  surface  ought  to  be  thoroughly  tested  with  a  wedge-pointed  in- 
strument, and  wherever  the  point  can  be  forced  into  the  gold,  the 
cavity  thus  formed  should  be  filled.  The  instrument  employed  for 
the  introduction  of  the  gold  may  be  like  the  one  represented  in  Fig- 
331,  but  having  a  rather  longer  point,  and  grasped  as  in  Fig.  328. 
For  condensing  the  extruding  portions,  either  or  both  of  the  instru- 
ments represented  in  Figs.  325  and  329  may  be  used,  as  also  the  one 
employed  for  the  introduction  of  the  gold.     During  this  part  of  the 


506 


DENTAL   SURGERY. 


Fig.  338. 


Fig.  337.  operation,    the    instrument    may    be 

held  as  before,  or  as  seen  in  Fig.  338, 
which  permits  a  much  greater  amount 
of  force  to  be  applied  than  when  held 
in  any  other  manner. 

Nearly  the  same  method  and  the 
same  instruments  ai-e  required  for 
filling  a  corresponding  cavity  on  the 
opposite  side  of  the  jaw.  When  prac- 
ticable, the  forefinger  of  the  left  hand 
should  be  placed  on  the  palatine  sur- 
face of  the  tooth,  and  the  thumb 
against  the  buccal  surface,  and  in 
addition  to  the  instruments  recom- 
mended for  the  right  side  of  the 
mouth,  the  one  shown  in  Fig.  323  may 
be  very  conveniently  employed  to 
introduce  the  gold ;  also  Fig.  325  or 
339,  in  condensing  the  surface  of  the 
filling.  The  writer  finds  this  last  par- 
ticularly valuable  in  very  many  cases. 
A  cavity  in  the  posterior  approximal  surface  of  a  superior  bicuspid 
on  either  side  of  the  mouth,  can,  in  the  majority  of  cases,  be  as  easily 
filled  as  one  in  the  anterior  approximal  surface.  The  position  of  the 
left  hand  is  very  nearly  the  same,  and  in  the  introduction  of  the  gold 
the  first  folds  are  placed  against  the  palatine  wall  of  the  cavity.  By 
commencing  on  this  side,  the  operator  is  enabled  to  lay  the  folds  more 
compactly  than  he  could  were  he  to  commence  at  any  other  point. 
He  also  has  a  more  perfect  control  over  the  instrument  in  this  part  of 
the  operation,  and  has  a  better  view  of  the  cavity  during  the  intro- 
duction of  the  gold.  For  consolidating  the  filling,  the  instruments 
represented  in  Figs.  324,  325  and  330  are  as  well  adapted  to  the 
purpose  as  any  that  can  be  employed. 

When  the  mouth  of  a  patient  is  large,  a  filling  can  often  be  intro- 
duced with  nearly  as  much  ease  in  the  posterior  approximal  surface 
of  a  first  or  even  a  second  upper  molar  as  in  that  of  a  bicuspid ;  but 
when  the  mouth  is  small  and  the  cheeks  fleshy,  it  often  becomes  a 
difiicult  and  perplexing  operation,  although  the  same  method  is  used  ; 
yet,  as  it  is  absolutely  necessary  to  the  introduction  of  a  good  filling 
that  the  operator  should  see  the  cavity  and  witness  every  part  of  the 
operation,  his  ingenuity  is  often  taxed  to  the  utmost  in  contriving  the 
most  suitable  means  to  enable  him  to  do  it.  A  number  of  instruments 
for  drawing  back  the  corner  of  the  mouth  have  been  invented ;  but  the 


FILLING   THE    SUPERIOR    MOLARS    AND    BICUSPIDS.  507 

writer  believes  there  are  none  so  well  suited  to  the  purpose  as  the 
thumb  or  forefinger  of  the  left  hand  of  the  operator.  If  the  operator 
will  accustom  himself  to  the  use  of  a  small  mouth-glass  held  in  the 
left  hand  whilst  operating,  he  will  be  spared  many  back-breaking 
efforts  to  keep  in  view  fillings  on  posterior  surfaces.  It  is  necessary  to 
become  familiar  with  the  apparently  reverse  motion  of  the  instrument 
as  seen  in  the  glass ;  also  to  accustom  the  three  fingers  of  the  left 
hand  to  act  independently  of  the  thumb  and  forefinger.  But  one  of 
the  most  careful  and  skillful  operators  of  this  or  any  other  country, 
Dr.  Maynard,  assures  us  that  he  works  from  a  reflected  view  in  the 
glass  with  the  same  ease  as  where  he  has  a  direct  view  of  the  cavity, 
and  obtains,  in  very  many  cases  where  he  uses  the  glass,  an  accuracy 
of  view  which  direct  vision  could  not  give  him. 

Before  dismissing  this  part  of  the  subject,  there  is  one  point  to  which 
the  attention  of  the  young  practitioner  should  be  particularly  directed. 
Many,  in  other  respects  tolerably  good  operators,  are  most  likely  to 
fail  in  not  introducing  a  sufficient  quantity  of  gold  in  the  upper  pala- 
tine portion  of  the  cavity.  The  author  frequently  meets  with  cases 
in  which  the  walls  of  the  cavity  are  perfectly  sound,  and  every  other 
part  of  the  filling  well  consolidated ;  but  here,  upon  the  application 
of  a  wedge-pointed  instrument,  the  gold  is  easily  perforated.  He 
would  therefore  advise  the  inexperienced  operator  to  test  this  by  severe 
pressure  with  a  sharp,  wedge-pointed  instrument,  as  well,  indeed,  as 
every  part  of  the  filling,  before  leaving  the  operation.  There  is  also 
one  other  precaution  applicable  to  fillings  in  the  approximal  surfaces 
of  the  incisors  and  cuspids,  as  well  as  of  the  molars  and  bicuspids ;  it 
relates  to  overlapping  portions  of  gold  under  the  free  edge  of  the  gum, 
which  must  be  carefully  and  completely  removed  before  the  operation 
can  be  regarded  as  complete. 

In  filling  a  cavity  in  the  buccal  surface  of  an  upper  bicuspid  or 
molar,  on  either  side  of  the  mouth,  the  gold  may  be  introduced  with 
the  instruments  represented  in  Figs.  321  and  331.  The  latter  is  better 
adapted  for  the  left  side,  but  may  also  be  used  on  the  right.  The 
straight,  wedge-pointed  instrument  may  also  be  advantageously  em- 
ployed on  this  side.  The  first  folds  of  gold  should  be  placed  against 
the  posterior  wall,  proceeding  from  behind  forward,  and  pressing  the 
folds  against  each  other  as  compactly  as  possible.  When  the  cavity 
has  a  large  orifice,  and  is  rather  shallow,  or  in  other  respects  badly 
shaped  for  the  retention  of  the  gold,  the  operation  is  often  tedious,  dif- 
ficult and  perplexing.  But  under  favorable  circumstances  a  filling 
may  be  almost  as  readily  introduced  here  as  in  any  other  part. 

The  palatine  surface  of  a  bicuspid  or  of  a  molar  is  rarely  attacked 
by  caries ;  on  the  latter,  it  is  usually  seated  in  a  depression  at  the  termi- 


508  DENTAL   SURGERY. 

nation  of  a  fissure  leading  from  the  posterior  depression  in  the  grinding 
surface.  It  is  usually  situated  near  the  posterior  palato-approximal 
angle  of  the  crown,  about  half  way  between  the  gum  and  the  coronal 
extremity  of  the  tooth.  It  sometimes  happens  that  the  walls  of  these 
fissures  are  affected  with  caries  throughout  their  whole  extent,  requiring 
to  be  filled  from  the  depression  in  the  grinding  to  its  termination  on 
the  palatine  surface.  In  this  case,  the  portion  of  the  cavity  on  the 
grinding  surface  may  be  first  filled  ;  then  the  operator  may  proceed  to 
fill  the  palatine  portion  in  the  same  manner  as  if  it  were  a  simple 
cavity,  placing  the  first  folds  of  foil,  in  the  case  of  a  right  molar, 
against  the  upper  and  posterior  side  of  the  opening,  with  an  instrument 
like  the  one  represented  in  Fig.  331.  Great  care  is  necessary  to  pre- 
vent the  instrument  from  slipping.  It  often  happens,  too,  that  the 
orifice  becomes  choked  with  foil  before  the  cavity  is  -half  filled.  This, 
indeed,  is  liable  to  occur  in  filling  any  cavity  in  any  tooth  ;  and  when 
it  does  happen,  unless  a  sufficient  amount  of  pressure,  is  applied  to 
make  a  free  opening  into  it,  the  filling  will  be  imperfect,  and  the  object 
of  the  operation  wholly  defeated.  When  the  cavity  is  situated  in  a 
left  molar,  the  gold  may  be  introduced  with  the  instruments  repre- 
sented in  Figs.  321  and  334,  placing  the  first  folds  against  the  upper 
wall  of  the  cavity,  and  proceeding  downward. 

A  tubercle,  of  greater  or  less  size,  is  sometimes  found  on  the  anterior 
palatine  surface  of  a  molar,  near  the  crown.  Between  this  and  the 
body  of  the  crown  a  deep  depression  is  often  seen,  which  becomes  the 
seat  of  caries ;  but  the  removal  of  the  diseased  part,  and  the  introduc- 
tion of  a  filling  is  so  simple,  that  a  special  description  of  the  operation 
is  not  deemed  necessary. 

II.  With  Cohesive  Gold  Foil. — In  forming  cavities  in  the  approximal 
surfaces  of  bicuspids  and  molars,  it  is  essential,  in  the  majority  of  cases, 
to  separate  the  teeth  either  by  means  of  pressure  or  by  cutting  away  a 
portion  of  the  crown. 

When  they  are  very  close  together,  it  is  often  impossible  to  gain  suffi- 
cient space  by  pressure,  and  it  then  becomes  necessary  to  resort  to  the 
enamel  chisel  and  file  or  disk,  cutting  away  a  portion  from  each  tooth, 
when  both  are  decayed,  and  from  one  only,  if  the  other  is  in  a  sound 
condition.  The  former  practice  in  separating  these  teeth  was  to  cut  away 
so  much  of  the  entire  approximal  surface  as  to  form  a  v-shaped  space 
of  sufficient  extent  to  enable  the  operator  to  reach  the  cavity  easily. 
But  by  this  method  the  crown  of  the  tooth  was  disfigured,  and  a  space 
formed  in  which  food  readily  collected,  and  became  a  source  of  con- 
siderable annoyance.  To  avoid  this,  the  practice  now  is  to  cut  through 
the  grinding  surface  to  the  approximal  cavity,  mortising  this  opening, 
and  thus  preserve  the  palato-  and  bucco-approximal  angles,  while  at  the 


FILLING   THE   SUPERIOR   MOLAES   AND    BICUSPIDS. 


509 


same  time  the  shape  of  the  opening  through  the  grinding  surface  ma- 
terially assists  in  the  retention  of  the  filling.  In  preparing  these  cavi- 
ties for  cohesive  gold  foil,  at  least  two  good  retaining  points  should 
be  made  at  the  cervical  wall  and  two  under-cuttings  at  the  cusps,  which 
have  been  preserved  by  the  method  of  gaining  space  just  described. 
But  one  of  these  retaining  points,  in  connection  with  the  two  under- 
cuttings  at  the  cusps,  will  often  secure  the  filling,  when  the  nature  of 
the  case  will  not  allow  of  more  being  made. 

In  preparing  a  cavity  on  the  posterior  approximal  surface  of  a 
molar  tooth,  access  is  obtained  by  cutting  through  the  grinding  sur- 
face in  the  manner  before  referred  to;  then,  by  means  of  instruments 
more  or  less  curved,  the  buccal  and  palatine  walls  are  made  parallel 
Avith  each  other,  under-cuttings  formed  at  the  cusps,  and  retaining 
points  drilled  in  the  cervical  wall  at  difierent  angles.  Advantage  is 
also  gained  from  having  the  cervical  wall  slightly  undercut.  In  intro- 
ducing the  gold  into  a  cavity  of  this  nature,  many  prefer  placing  a 
polished  plate  of  metal  or  a  matrix  back  of  the  cavity,  in  the  space 
between  the  teeth,  and  condensing  the  gold  firmly  against  it  in  building 
up  this  portion  of  the  crown.  By  this  method  a  good  support  is  ob- 
tained, and  after  all  the  gold  necessary  is  introduced  and  consolidated, 
the  metal  j)late  is  removed. 

Fig.  340  represents  a  set  of  Loop  Matrices,  consisting  of  thin,  flex- 


FiG.  340, 

/Qv     ^     ^     /P?^     ^     ^^     '-^    ^,^ 


ible  steel  bars  and  a  milled  thumb-screw.  To  use  them,  one  of  the 
proper  size  is  selected,  the  head  with  the  smooth  hole  being  2:)assed  over 
the  thumb-screw,  the  screwed  head  is  then  bent  axound  and  the  loop 
screwed  to  its  place  on  the  tooth. 

Fig.  341  represents  an  ingenious  mechanical  aid  of  this  description, 
invented  by  Dr.  liouis  Jack,  called  a  Matrix ;  a  shows  the  concave 
and  wedging  sides  of  a  matrix,  and  b  shows  a  matrix  placed  between 


510  DENTAL   SURGERY. 

two  teeth  ready  to  wedge  and  fill,     c  represents  the  form  of  pliers  for 
placing  a  matrix  in  position. 

Fig.  341. 

b 

_ "  T 


The  points  especially  notable  in  the  use  of  the  matrix  are,  to  cut 
•  away  the  raasticatiug  surface  of  enamel  to  the  depth  of  the  cavity;  to 
prepare  the  edges  flat  and  smooth  ;  to  cut  down  to  sound  bone  in  the 
neck  of  the  tooth,  forming  the  base  of  the  cavity,  and  shaping  it  so 
that  the  matrix  will  fit  accurately  on  the  cervical  wall.  Having  exca- 
vated the  cavity  and  cut  a  retaining  groove  along  the  buccal  and  pal- 
atal walls  (terminating  at  the  very  surface  of  the  masticating  walls  of 
the  enamel),  select  a  matrix,  the  concaved  surface  of  which  matches 
the  cavity.  Then,  after  applying  the  rubber  dam,  finish  and  dry  the 
cavity,  place  the  matrix,  and  secure  it  with  wedges  of  boxwood,  which 
being  hard  and  dry  require  very  little  forcing.  The  filling  may  then 
be  done  with  the  ease  and  certainty  of  a  crown  cavity  with  strong 
walls. 

In  filling  grinding  surface  cavities  in  the  molar  teeth,  where  the  de- 
cay has  extended  along  one  or  more  of  the  crown  fissures,  with  cohe- 
sive gold  fi)il  or  crystal  gold,  the  gold  is  first  introduced  into  the 
bottoms  of  the  crown  fissures,  and  built  up  to  their  orifices,  thus  com- 
pleting the  filling  of  these  fissures  before  the  central  cavity  is  filled. 
In  preparing  cavities  extending  in  the  form  of  grooves  over  the  buccal 
and  palatine  surfaces  of  the  bicuspids  and  molars,  all  projecting  por- 
tions of  enamel  should  be  cut  away,  so  as  to  allow  these  cavities  to  be 
but  little  larger  within  than  at  their  orifices ;  and  the  ends  of  the 
groove,  which  are  usually  shallow,  should  be  made  as  deep  as  the  cen- 
tre. One  retaining  point  may  then  be  made  in  each  of  the  two  walls 
forming  the  ends  of  the  groove-like  cavity,  or  one  retaining  point  in 
the  posterior  wall,  in  connection  with  an  under-cutting  in  the  anterior 
one,  will  answer  for  the  retention  of  the  filling.  In  introducing  the 
gold  into  a  cavity  of  this  form,  the  retaining  points  are  first  filled  and 
the  gold  built  across  the  floor  of  the  cavity  from  one  to  the  other,  and 
from  the  base  thus  formed   to  the  orifice.      When  a  cavity  upon  the 


FILLING   THE   INFERIOR   INCISORS    AND    CUSPIDS.  511 

buccal  or  palatine  surface  extends  under  the  free  margin  of  the  gum, 
it  is  necessary  to  either  force  the  gum  away  by  pressure  with  pledgets 
of  cotton  saturated  with  chloride  of  zinc,  when  the  cavity  is  not  too  near 
the  pulp,  or  to  remove  the  portion  overlapping  the  cavity.  The  hem- 
orrhage which  follows  this  latter  method  may  be  checked  by  any  of  the 
hfemostatic  agents  in  use,  such  as  tannin,  phenol  sodique,  creasote, 
powdered  sulphate  of  iron,  etc. 

The  application  of  chloride  of  zinc  will  prove  very  effectual  in  such 
cases ;  also  nitrate  of  silver,  but  the  latter  agent  has  a  tendency  to 
discolor  the  dentine. 

FILLING   THE   INFERIOR   INCISORS   AND   CUSPIDS. 

The  operation  of  filling  a  lower  incisor  or  cuspid  is  far  more  difficult 
than  filling  an  upper.  It  is  fortunate,  therefore,  both  for  the  dentist 
and  the  patient,  that  the  lower  incisors  and  cuspids  are  less  liable  to 
caries  than  the  upper,  owing  to  their  being  constantly  bathed  in 
saliva. 

The  constant  tendency  of  the  lower  jaw  to  change  its  position  is 
embarrassing  to  the  dentist  in  operating  on  any  of  the  teeth  in  it,  and  in 
case  of  the  incisors  and  cuspids  it  is  sometimes  peculiarly  perplexing. 
To  prevent  this,  all  the  effort  the  operator  can  make  with  his  left  hand 
is  frequently  required.  From  the  backward  inclination,  too,  of  these 
teeth,  it  rarely  happens  that  the  gold  can  be  introduced  from  the  lin- 
gual side  of  the  arch  ;  consequently,  it  is  necessary  to  make  the  space 
as  wide  anteriorly  as  posteriorly.  But  as  the  teeth  are  comparatively 
small,  the  separation,  when  made  with  a  file,  disk,  etc.,  should  be  no  wider 
than  is  absolutely  necessary  for  the  removal  of  the  diseased  part  and  the 
introduction  of  the  gold.  When,  however,  it  can  be  done  with  safety, 
the  separation  should  be  made  with  a  piece  of  rubber  or  other  substance 
between  the  teeth,  in  the  manner  before  described. 

While  operating  on  the  lower  teeth,  the  head  of  the  patient  should 
occupy  a  more  perpendicular  position  than  while  operating  on  the 
upper ;  this  may  be  done  either  by  lowering  the  seat  or  raising  the 
head-piece  of  the  chair.  When  by  the  latter,  it  will  be  occasionally 
necessary  for  the  operator  to  stand  upon  a  stool  five  or  six  inches  in 
height. 

In  filling  a  cavity  in  the  right  approximal  surface  of  a  lower  incisor 
or  cuspid  with  non-adhesive  gold  foil,  the  following  method  is  recom- 
mended. The  cavity  being  prepared,  and  a  sufficient  quantity  of  gold 
foil  made  into  a  small  roll,  or  folded  lengthwise,  as  the  operator  may 
prefer,  with  the  left  arm  over  the  patient's  head,  the  chin  is  gently 
grasped  with  the  left  hand,  while  the  thumb  is  placed  against  the 
lingual  surface  of  the  tooth,  the  forefinger  serving  to  direct  the  gold 


512  DENTAL   SURGERY. 

and  point  of  the  instrument,  and  also  to  depress  the  lower  lip.  The 
folds  of  gold  in  their  introduction  are  pressed  firmly  against  the  lower 
wall  of  the  cavity.  The  instrument  employed  for  this  purpose  may 
be  shaped  like  the  one  represented  in  Fig.  342,  with   a  very  small 

Fig.  342.  Fig.  343. 


wedge-shaped  point,  and  held  as  in  Fig.  328.  The  consolidation  of  the 
gold  may  be  effected  partly  with  the  same  instrument,  partly  with  a 
round-pointed  one,  shaped  as  shown  in  Fig.  343,  and  partly  with  an 
instrument  shaped  as  in  Fig.  330.  The  tooth  should  be  firmly  held 
between  the  thumb  and  forefinger  of  the  left  hand,  to  prevent  it  from 
being  moved  in  its  socket  by  the  pressure  of  the  instrument. 

When  the  incisors  are  very  small,  and  the  caries  has  spread  over  a 
large  portion  of  the  side  of  the  tooth,  it  is  often  difficult  to  form  a 
suitable  cavity  for  the  retention  of  a  filling  without  penetrating  to  the 
pulp  cavity.  In  such  cases,  the  patieuce  and  skill  of  the  operator  are 
frequently  taxed  severely  in  obtaining  a  sufficiently  secure  support  for 
the  gold.  But  this  he  can  usually  do,  if  he  can  make  the  bottom  of 
the  cavity  as  large  as  the  orifice,  even  though  it  have  but  little  depth. 

The  manner  of  introducing  a  filling  in  the  left  approximal  surface 
is  very  similar.  The  left  arm  and  hand,  as  well  as  the  thumb  and 
forefinger,  are  all  disposed  of  in  the  manner  just  described.  The  same 
instruments,  too,  may  be  employed  for  introducing  and  consolidating 
the  gold,  though  in  the  first  part  of  the  operation  the  instrument  Fig. 
326  may  often  be  advantageously  substituted  for  the  one  in  Fig.  342. 
The  instruments  known  as  "  rights  and  lefts,"  of  different  sizes,  are 
very  serviceable  for  filling  all  approximal  cavities. 

Nothing  has  been  said  with  regard  to  fillings  in  the  labial  or  lingual 
surfaces  of  lower  incisors  and  cuspid*.  Although  caries  rarely  attacks 
either  of  these  surfaces  of  a  lower  incisor,  it  does  sometimes  develop 
itself  in  the  labial  surface  of  a  cuspid ;  but  the  operation  of  intro- 
ducing a  filling  here  is  so  simple,  that  a  separate  description  of  the 
manner  of  it  is  not  deemed  necessary. 

The  operation  of  forming  cavities  in  the  inferior  teeth  and  intro- 
ducing cohesive  gold  foil  and  crystal  gold  is  the  same  as  that  described 
for  the  superior  teeth,  and  a  second  description  is  therefore  not  con- 
sidered necessary.  As  absolute  dryness  is  essential  in  manipulating 
with  the  cohesive  forms  of  gold,  the  reader  is  referred  to  the  various 
methods  and  appliances  before  described  for  drying  cavities  and  pro- 
tecting them  from  moisture.  In  filling  the  inferior  teeth,  the  rubber 
coffer-dam  will  be  found  to  be  a  valuable  appliance  for  excluding  all 


FILLING   THE   INFERIOR   MOLARS    AND   BICUSPIDS.  513 

moisture  from  both  the  gold  and  cavity,  and  the  saliva-pump  an 
efficient  adjunct  to  this  dam  for  relieving  the  mouth  of  the  saliva  as 
it  accumulates  in  prolonged  operations.  For  controlling  the  move- 
ments of  the  tongue,  a  tongue  and  duct  compressor  has  been  used  in 
connection  with  pads  of  bibulous  paper  placed  upon  the  mouths  of  the 
ducts  beneath  the  tongue.  Prepared  spunk  has  also  been  used  suc- 
cessfully on  the  mouths  of  the  sublingual  and  submaxillary  ducts, 
for  controlling  the  flow  of  saliva. 

FILLING   THE   INFERIOR   MOLARS   AND    BICUSPIDS. 

In  filling  a  cavity  in  the  grinding  surface  of  a  right  lower  molar  or 
bicuspid,  the  operator  may  stand  on  the  same  side  of  his  patient,  and 
a  few  inches  higher  than  while  operating  on  an  incisor  or  cuspid. 
With  his  left  arm  placed  over  his  patient's  head,  the  tooth  may  be 
grasped  with  the  thumb  and  forefinger  of  the  left  hand,  while  the 
middle  finger  is  placed  by  the  side  of  the  chin  ;  the  other  two  should 
be  placed  beneath  it.  After  preparing  the  cavity,  non-cohesive  gold 
foil  may  be  introduced  with  an  instrument  like  the  one  represented  in 
Fig.  334,  and  held  as  shown  in  Fig.  328,  pressing  the  folds  against  the 
posterior  walls  of  the  cavity. 

In  condensing  the  gold  after  the  cavity  is  filled,  use  the  instrument 
represented  in  Fig.  335.  Sometimes,  however,  a  greater  amount  of 
force  can  be  exerted  when  this  instrument  is  held  in  the  manner  shown 
in  Fig.  338,  previously  wrapping  it  with  the  corner  of  a  napkin,  to 
prevent  the  small  part  of  the  instrument  from  hurting  the  little  finger. 
The  kind  of  instrument,  and  the  manner  of  holding  it,  will,  after  all, 
have  to  be  determined  by  the  operator.  During  the  introduction  and 
consolidation  of  the  gold,  the  lower  jaw  should  be  firmly  held  with  the 
left  hand,  to  prevent  it  from  moving,  and  from  being  too  much  de- 
pressed. This  precaution  is  the  more  necessary,  as  the  muscles  of  the 
lower  jaw  and  the  articular  ligaments  are  seldom  strong  enough  to 
resist  the  amount  of  force  required  in  the  operation. 

In  filling  a  cavity  in  the  grinding  surface  of  a  tooth  on  the  left  side, 
the  dentist  may  sometimes  operate  to  greater  advantage  by  standing 
on  the  same  side.  In  this  case,  the  commissure  of  the  lips  should  be 
pressed  back  with  the  thumb  of  the  left  hand,  placing  it  on  or  against 
the  tooth  to  be  filled,  while  the  forefinger  passes  in  front  of  the  chin, 
and  the  other  three  beneath  it.  As  a  general  rule,  however,  he  will  be 
able  to  operate  more  conveniently  by  standing  on  the  right  side  of 
his  patient,  and  holding  the  tooth  and  the  chin  in  the  manner  before 
directed.  In  either  case,  the  gold,  in  its  introduction,  should  be 
pressed  against  the  posterior  wall  of  the  cavity. 

The  foregoing  general  directions  will  be  found,  for  the  most  part, 
33 


514  DENTAL   SURGERY. 

applicable  to  the  introduction  of  a  filling  in  the  approxiraal  surfaces. 
When  the  crowns  of  the  teeth  are  long,  and  the  cavity  situated  near 
the  gum,  the  operation  is  sometimes  very  difficult  and  tedious,  requir- 
ing all  the  patience  and  skill  the  dentist  can  exercise  to  accomplish  it 
securely.  This  difficulty  is  increased  when  the  shape  of  the  cavity  is 
unfavorable  for  the  retention  of  the  gold ;  or,  in  other  words,  when 
the  cavity  is  shallow,  and  has  a  large  orifice.  There  is  also  another 
very  serious  difficulty  which  the  operator  encounters  in  the  introduc- 
tion of  a  filling  in  the  approximal,  and  also  in  the  buccal,  surface  of 
a  lower  molar  or  bicuspid.  The  flow  of  saliva  is  often  so  profuse  that 
the  whole  of  the  lower  part  of  the  mouth  is  completely  filled,  and  the 
tooth  is  inundated,  before  it  is  possible  to  introduce  a  sufficient  quantity 
of  gold  to  fill  the  cavity.  This  not  only  retards  the  operation,  but  it 
also  renders  it  more  difficult  and  perplexing ;  for  it  is  necessary  to 
force  out  every  particle  of  moisture  from  the  cavity  and  from  between 
the  different  layers  of  gold,  before  the  necessary  cohesive  attraction 
between  them  can  be  secured.  If  this  is  not  done,  or,  at  any  rate,  if 
all  the  moisture  is  not  forced  from  the  cavity,  and  the  gold  sufficiently 
consolidated  to  render  it  impermeable  to  the  fluids  of  the  mouth,  the 
operation  will  be  unsuccessful,  to  a  great  extent ;  hence  the  rubber 
dam  is  a  valuable  adjunct. 

Ordinary  foil  (non-cohesive),  when  introduced  in  folds  lying  parallel 
with  the  sides  of  the  cavity,  keeps  its  place  by  the  close  lateral  contact 
of  the  folds  against  each  other  and  the  walls  of  the  cavity.  Hence  such 
fillings  may  prove  successful,  although  done  "  under  water,"  provided 
the  lateral  pressure  is  sufficient  to  force  out  the  saliva  from  between 
the  layers  of  foil.  But  if  the  folds  are  laid  in  parallel  with  the  bottom 
of  the  cavity,  the  operation  will  fail,  in  consequence  of  the  scaling  off 
of  the  successive  layers  which  have  no  adhesion.  Crystal  gold  and 
cohesive  foil  fillings  depend  for  their  success  upon  the  perfect  adhesion 
of  their  component  pieces  ;  therefore,  the  slightest  moisture,  or  even 
dampness,  while  being  introduced,  is  fatal  to  their  durability. 

For  the  purpose  of  obviating  this  difficulty,  a  variety  of  means  have 
been  proposed,  the  most  important  of  which  have  already  been  de- 
scribed, and  need  not  be  again  referred  to. 

In  the  introduction  of  non-cohesive  gold  on  the  right  side,  it  may  be 
pressed  against  the  buccal  wall  of  the  cavity  on  the  left  side,  or  against 
the  lingual  wall.  Either  of  the  instruments  represented  in  Figs.  320 
and  331  may  be  employed  for  the  introduction  of  the  gold,  whether 
the  cavity  be  situated  in  the  anterior  or  posterior  approximal  surface 
of  the  tooth,  and  may  be  held  in  the  hand  in  the  manner  shown  in 
Fig.  328  or  332. 

In  filling  a  cavity  in  the  lingual  and  posterior  approximal  angle 


FILLING  THE    INFERIOR   MOLAES   AND   BICUSPIDS.  515 

of  a  first  or  second  bicuspid,  and  especially  from  the  loss  of  the  tooth 
behind  it,  when  there  is  a  backward  inclination  of  the  organ,  great 
care  is  necessary  to  prevent  the  instrument  from  slipping  and  wound- 
ing the  lower  lip.  The  most  convenient  position  for  the  operator  in 
this  case  is  on  the  left  side,  and  partly  in  front  of  the  patient.  The 
tooth  may  then  be  firmly  grasped  between  the  thumb  and  forefinger 
of  the  left  hand,  or  the  thumb  alone  pressed  against  the  outside  of 
the  tooth  ;  in  either  case  it  is  to  be  used  as  a  rest  for  the  ring  finger  of 
the  right  hand,  during  the  introduction  and  consolidation  of  the  gold. 
But  the  locality  of  the  cavity  is  such,  especially  when  the  mouth  of 
the  patient  is  small,  that  it  can  only  be  seen  with  great  diflBculty. 
Hence  the  operator  is  constantly  liable  to  place  the  point  of  the 
instrument  on  one  side  of  the  orifice,  against  an  overlapping  portion 
of  gold,  which,  when  pressure  is  applied,  is  cut  through  or  detached. 
The  instrument  thus  comes  in  contact  with  the  hard,  smooth  enamel, 
and  unless  the  hand  is  so  guarded  as  to  control  its  motions,  it  is  liable 
to  slip  and  wound  some  part  of  the  mouth,  especially  the  lower  lip, 
which  accident,  unless  proper  precaution  is  observed,  may  occur  in 
filling  any  tooth. 

Among  the  principal  difficulties  which  the  dentist  encounters  in 
filling  a  cavity  in  the  buccal  surface  of  a  lower  molar,  apart  from  that 
of  keeping  the  cavity  dry  until  the  gold  is  introduced,  is  the  contact 
of  the  lower  and  inner  part  of  the  cheek  with  the  tooth.  This  may, 
to  a  considerable  extent,  be  prevented,  and  the  commissure  of  the  lips 
at  the  same  time  pushed  back  with  the  forefinger  of  the  left  hand  of 
the  operator,  which  also  will  serve,  when  the  cavity  is  shallow  and  the 
orifice  large,  to  hold  the  gold  in  place,  until  a  sufficient  quantity  is 
introduced  to  obtain  support  from  the  surrounding  walls.  In  operating 
upon  the  bicuspids,  it  is  only  necessary  to  depress  the  corner  of  the 
mouth  to  obtain  free  access  to  the  cavity. 

For  the  introduction  of  the  gold  on  the  right  side,  either  of  the 
instruments  represented  in  Figs.  321  and  331  may  be  employed,  but 
on  the  left  side  the  latter  will  generally  be  found  most  convenient.  A 
straight,  wedge-pointed  instrument  (Fig.  344)  can  often  be  advanta- 
geously used  in  introducing  the  foil  in  either  of 
the  right  bicuspids,  and  sometimes  even  in  the  ^^-  ^^'^• 

first  molar.  This  instrument  can  also  often  be 
used  in  filling  a  cavity  in  the  grinding  surface 
of  a  molar  of  either  jaw,  but  oftener  in  the  upper  than  the  lower.  It 
is  scarcely  necessary  to  say,  that  the  introduction  of  the  gold  should 
commence  behind  and  proceed  forward.  The  instruments  represented 
in  Figs.  324,  337  and  333  may  be  used  in  consolidating  the  foil. 

It  may  be  well  to  mention  here,  that  in  filling  a  molar  or  bicuspid 


516  DENTAL   SURGERY. 

on  the  left  side  in  the  lower  jaw,  whether  in  the  grinding,  approximal 
or  buccal  surface,  the  back  of  the  chair,  if  so  constructed  as  to  admit 
of  being  moved,  should  be  thrown  five  or  six  inches  further  back,  to 
lower  the  head  of  the  patient,  and  give  the  face  a  more  horizontal 
inclination.  By  this  means  the  operator  is  enabled  to  approach  the 
locality  of  his  manipulations  with  greater  ease,  thus  enabling  him  to 
exercise  a  more  perfect  control  over  his  instrument,  as  w-ell  as  over  the 
mouth.  But  if  the  back  of  his  operating  chair  is  stationary,  he  should 
stand  upon  a  stool  of  five  or  six  inches  in  height. 

The  precaution  of  removing  all  the  overlapping  portions  of  gold 
should  never  be  omitted,  and  this  sometimes  constitutes  a  difficult  part 
of  the  operation,  especially  when  the  cavity  extends  under  the  margin 
of  the  gum.  For  this  purpose,  some  of  the  files  represented  in  Fig. 
313  may  be  very  advantageously  used.  Some  are  made  straight  at 
each  end,  others  are  curved.  These  valuable  instruments  were  first 
invented  by  Dr.  Elisha  Townsend ;  they  are  very  useful,  not  only  for 
the  purpose  just  stated,  but  also  for  filing  down  the  surplus  gold  of  a 
filling  in  the  approximal  and  other  surfaces  of  all  the  teeth. 

The  profession  is  now  well  supplied  with  these  files,  having  an  almost 
endless  variety  of  shape,  size,  and  fineness  of  cut.  It  is  difficult  to 
over-estimate  the  utility  of  these  indispensable  instruments.  Different 
makers  seem  to  vie  with  each  other  in  devising  new  forms.  A  valuable 
modification  has  been  suggested  by  Dr.  Edward  Maynard.  It  is  to 
make  the  two  ends  different — not  in  shape,  as  is  usually  done,  but  in 
the  direction  of  the  file-cut ;  or  rather,  to  have  the  file  on  each  end  set 
in  the  same  direction,  marked  by  an  arrow  on  the  shaft.  Thus  one 
end  will  cut  toward,  the  other  from  the  operator;  which,  as  the  two 
movements  are  constantly  required  upon  the  same  filling,  adds  greatly 
to  the  value  of  the  instrument.  Whereas  a  difference  in  the  shape  of 
the  two  ends  is  rather  an  annoyance,  and  precise  similarity  of  no  use, 
except  on  the  score  of  economy. 

The  foregoing  details  with  regard  to  the  manner  of  filling  teeth  will 
serve  as  a  general  guide  for  the  performance  of  the  operation,  and  at 
the  same  time  give  to  the  student  and  inexperienced  practitioner  some 
idea  of  the  amount  of  labor,  accuracy  of  manipulation,  and  perfection 
of  execution  it  requires. 

The  manner  of  building  up  the  whole  or  a  part  of  the  crown  of  a 
tooth  will  now  be  described. 

CONTOUR   FILLINGS. 

The  term  "contour"  signifies  "the  line  that  bounds,  defines,  or 
terminates  a  figure ;""  hence  a  "contour  filling"  is  one  that  is  made  to 
conform  to  the  line  that  defined  the  contour  of  the  lost  tooth  tissue ;  in 


CONTOUR    FILLINGS.  517 

other  words,  the  filling  material  is  built  up  to  such  a  degree  as  is 
necessary  to  restore  the  original  form  of  the  crown  of  the  tooth. 

It  is  scarcely  to  be  expected  that  any  one  who  has  not  had  consider- 
able experience  in  filling  teeth,  and  acquired  a  high  degree  of  dexterity 
in  the  use  of  instruments  and  the  working  of  some  one  or  more  of  the 
preparations  of  gold  employed  for  the  purpose,  such  as  cohesive  gold, 
will,  simply  from  any  directions  that  can  be  laid  down  upon  the  sub- 
ject, be  able  at  once  to  perform  the  operation  of  building  on  the  whole 
or  part  of  the  crown  of  a  tooth.  But  it  is  hoped  that  the  following 
description  may  serve  as  a  guide  to  those  who  have  never  attempted 
it,  and  may  wish  to  exercise  their  mechanical  and  artistic  abilities  on 
this,  the  most  difficult  of  all  operations  in  dentistry.  Those  only  who 
are  aiming  at  high  excellence  in  this  department  of  practice  will  be 
likely  to  undertake  it;  and  should  their  first  efforts  prove  unsuccessful, 
the  increase  of  skill  they  will  have  thus  acquired  in  the  use  of  instru- 
ments will  inspire  new  confidence,  and  ultimately,  by  perseverance, 
enable  them  to  achieve  the  object  of  their  wishes. 

The  operation,  to  be  successful,  must  not  only  be  performed  in  the 
most  perfect  manner,  but  the  tooth  itself  must  be  situated  in  a  healthy 
cavity  and  firmly  articulated.  Under  other  circumstances  it  would  be 
useless  to  attempt  the  restoration  of  the  organ.  The  general  system, 
too,  should  be  free  from  any  preternatural  susceptibility  to  morbid 
impressions. 

A  tooth  on  which  this  operation  is  called  for  has,  in  nearly  every 
case,  suffered  so  much  loss  of  substance  as  to  render  it  necessary,  in 
cases  where  the  pulp  of  the  tooth  is  not  exposed,  that  great  care  should 
be  exercised  in  preparing  the  cavity  for  such  a  large  mass  of  filling 
material,  especially  gold,  and  securely  anchoring  it.  Where  the  ex- 
posure of  the  pulp  of  the  tooth  necessitates  the  destruction  and  removal 
of  this  organ,  the  operation  of  "contouring"  is  much  less  difficult,  as 
the  pulp  chamber  affords  secure  anchorage  for  the  filling.  Where  the 
pulp  has  previously  perished  from  inflammation  and  suppuration,  the 
permanent  preservation  of  the  organ  cannot  be  counted  on  with  as 
much  certainty  as  when  it  is  destroyed  by  extirpation,  or  by  the  appli- 
cation of  an  escharotic  two  or  three  days  before  the  performance  of  the 
operation.  Its  destruction  by  the  suppurative  process  is  more  apt  to 
be  followed  by  alveolar  abscess  ;  and  this  having  once  established 
itself,  is  seldom  so  completely  cured  as  to  prevent  the  liability  to  its 
recurrence.  Still,  if  the  operation  is  determined  on,  the  parts  of  the 
extremity  of  the  root  must  first  be  restored  to  health ;  for  without  this 
it  should  never  be  attempted.  The  preparatory  treatment  in  cases  of 
this  sort,  as  well  as  in  cases  of  siruple  morbid  secretion  escaping  from 
the  root,  is  given  in  another  chapter. 


518  DENTAL   SURGERY. 

Ill  describing  the  operation,  we  will  commence  with  the  first  molar 
of  the  left  side  of  the  superior  maxilla.  We  will  suppose  that  about 
three-fourths  of  the  crown  has  been  destroyed  by  caries,  and  that  the 
buccal  wall  is  the  only  portion  remaining,  the  pulp  being  more  or  less 
exposed.  This  is  to  be  destroyed  and  extirpated  to  the  extremity  of 
each  root ;  the  decayed  portions  of  the  tooth  are  then  to  be  removed, 
and  the  central  chamber  enlarged  until  the  wall  of  dentine  on  the 
palatine,  anterior  and  posterior  approximal  sides  are  only  about  one 
line  in  thickness.  On  the  inside  of  this  wall  a  shallow  groove  or  under- 
cut is  made,  and  also  retaining  points,  to  give  additional  security  to 
the  gold. 

The  tooth  as  now  prepared,  as  represented  in  Fig.  345,  and  after  the 
application  of  the  rubber  dam,  is  ready  for  the  introduction  and  build- 
ing on  of  the  gold.  But  before  describing  the  manner  of  doing  this,  it 
may  be  well  to  say  a  few  words  with  regard  to  the 
Fig.  345.  preparation  of  gold  most  proper  to  be  employed.     For 

filling  the  roots,  non-cohesive  gold  foil  is  the  best.  If 
the  leaves  are  thick,  weighing  from  fifteen  to  twenty 
grains,  it  should  be  introduced  in  very  narrow  strips, 
without  folding,  in  the  manner  described  in  another 
chapter ;  if  leaves  of  four  or  six  grains  are  preferred, 
it  may  be  cut  in  strips  varying  from  an  eighth  to  a 
quarter  of  an  inch  in  width,  according  to  the  size  of 
the  canal  in  the  root  and  then  rolled  or  made  into  very 
narrow  folds.  For  the  central  chamber  and  crown,  gold  possessing 
cohesive  properties  should  be  employed  ;  although  this  property  may, 
to  a  degree,  be  imparted  to  common  gold  foil  by  slightly  annealing 
immediately  before  using;  cohesive  gold  foil  possesses  it  in  a  higher 
degree,  and  this  also  requires  to  be  annealed.  Either  kind  of  foil, 
therefore,  or  crystal  gold  may  be  employed.  The  operation,  however, 
can  be  better  performed  with  the  cohesive  foil  or  crystal  gold  than 
•with  the  non-cohesive  foil.  Crystal  gold  is  often  used  to  fill  the  cen- 
tral chamber  and  act  as  a  base  upon  which  to  build  the  cohesive  gold 
foil. 

As  the  manner  of  filling  roots  is  described  in  another  place,  we  shall 
commence  with  the  pulp  cavity.  The  gold, supposing  it  to  be  cohesive 
foil,  is  loosely  rolled  into  a  fold  or  rope,  from  which  pellets  are  cut. 
A  sufficient  number  of  these  having  been  prepared,  the  surfaces 
against  which  the  gold  is  to  be  placed  are  made  perfectly  dry  by 
wiping  with  Japanese  bibulous  paper,  or  absorbent  cotton.  This  done, 
one  of  the  pellets  is  placed  in  the  central  chamber  with  pliers,  pressed 
into  a  retaining  point,  where  the  formation  of  such  points  is  necessary, 
and  consolidated  with  a  small-pointed  condensing  instrument ;  another 


CONTOUR   FILLINGS.  519 

and  another  is  added,  each  being  consolidated  as  the  first,  until  a  suf- 
ficient number  have  been  introduced  to  fill  this  chamber.  The  process 
of  consolidation  is  now  to  be  repeated  and  continued,  until  no  part  of 
the  gold  can  be  made  to  yield  to  the  pressure  of  the  instrument ;  then 
additional  pellets  are  applied  and  condensed,  as  in  the  first  instance, 
forcing  those  placed  against  the  surrounding  wall  firmly  and  com- 
pactly into  the  groove  or  undercut  made  in  it,  thus  securing  for  the 
entire  mass  the  greatest  possible  stability.  Again,  pellet  after  pellet 
is  applied,  pressing  those  placed  along  the  outer  edge  firmly  against 
the  exposed  margin  of  dentine  and  against  the  buccal  wall  of  the  tooth, 
until  a  solid  mass,  considerably  larger  than  the  portion  of  the  crown 
to  be  supplied,  shall  have  been  thus  formed.  The  same  result  may  be 
obtained  much  more  rapidly  by  using  the  gold  in  the  form  of  a  ribbon. 
In  this  case  fold  after  fold  of  the  gold  is  introduced,  each  fold  being 
thoroughly  welded  and  consolidated  as  introduced. 

For  the  complete  solidification  of  every  part  of  the  gold,  and  the 
welding  of  every  piece  to  the  adjoining  ones,  a  number  of  instruments 
are  required,  with  serrated  points,  which  are  represented  in  the  Figs. 
illustrating  the  instruments  employed  in  the  use  of  the  cohesive  forms 
of  gold.  For  some  parts  of  the  operation  a  straight  instrument  can 
be  employed  most  advantageously ;  for  other  parts,  one  slightly  bent 
near  the  point ;  and  for  others,  one  bent  at  right  angles  with  the  stem. 
The  kind  most  suitable  for  each  case  must  be  determined  by  the  judg- 
ment of  the  operator.  One,  perhaps,  may  use  very  efficiently  an  instru- 
ment, in  a  particular  locality  and  for  a  certain  purpose,  that  another,  for 
the  same  purpose,  would  handle  very  awkwardly.  But  for  completing 
the  work  of  consolidation,  all  agree  that  very  small-pointed  instru- 
ments are  indispensable. 

As  the  cohesiveness  of  the  gold  is  destroyed  by  the  contact  of  liquids, 
it  must  be  kept  absolutely  free  from  moisture  during  the  entire  process 
of  introducing  and  consolidating  the  metal.  But  if,  notwithstanding 
every  precaution,  the  saliva  should  come  in  contact  with  the  gold 
before  its  complete  introduction,  the  unfinished  surface  must  be  thor- 
oughly consolidated,  then  dried  with  some  good  absorbing  substance, 
scraped,  burnished,  dried  again,  and  made  rough  with  a  sharp-pointed 
instrument.  To  this  surface  fresh  portions  of  gold  can  now  be  united, 
and  sometimes  made  to  adhere  quite  firmly,  but  often  it  is  necessary 
to  drill  retaining  points  into  the  gold  and  continue  the  operation  from 
these  points.  The  use  of  the  rubber  dam  and  other  appliances  now 
enables  the  operator  to  perform  prolonged  operations  without  the  dan- 
ger from  moisture  which  formerly  existed. 

The  next  step  is  to  consolidate  thoroughly  every  part  of  the  surface. 
This  may  be  commenced  with  the  larger-pointed  instruments.     After 


520  DENTAL  SURGEEY. 

going  over  it  ten  or  a  dozen  times  with  these,  smaller  points  may  be 
used,  and  these  again  changed  for  still  smaller,  until  no  more  impres- 
sion can  be  made  upon  it  than  upon  a  solid  ingot  of  pure  gold.  ■ 

It  now  remains  to  cut  the  surface  until  the  gold  is  made  to  assume 
very  nearly  the  shape  of  that  portion  of  the  original  tooth  the  loss  of 
which  it  supplies.  The  plug  finishing  burrs  operated  by  the  dental 
engine,  the  files  for  finishing  the  surface  of  fillings,  and  the  corundum 
and  stone  disks  and  points,  Avill  be  found  serviceable  for  such  opera- 
tions. In  doing  this  an  opportunity  is  afibrded  to  the  operator  for  the 
display  of  much  artistic  skill  and  ingenuity.  While  shaping  the 
grinding  surface,  the  patient  should  be  requested,  from  time  to  time, 
to  close  the  mouth,  that  the  depressions  in  it  may  be  made  to  correspond 
to  the  cusps  of  the  tooth  with  which  it  antagonizes,  so  that  these  two 
may  touch  simultaneously  with  the  other  teeth  of  the  upper  and  lower 
jaws.  This  part  of  the  operation  is  always  tedious,  usually  requiring 
more  time  than  for  the  consolidation  of  the  gold.  The  use  of  articu- 
lation paper  may  facilitate  this  part  of  the  operation. 

The  surface  of  the  gold  may  now  be  rubbed  with  properly  shaped 

pieces  of  Arkansas  or  Hindostan  stone,  or  with  pulverized  pumice, 

until  all  the  scratches  left  by  the  file  are  removed ;  then 

polish  with  crocus  and  a  burnisher.     The  appearance 

of  the  tooth  as  thus  restored  is  shown  in  Fig.  346. 

As  it  is  impossible  to  perform  the  entire  operation  at 
one  time,  it  may  readily  be  divided  into  three  parts. 
The  first  consisting  in  the  extirpation  of  the  pulp  (when 
necessary)  and  the  preparation  of  the  tooth  ;  the  second, 
in  the  introduction  and  solidification  of  the  gold  ;  the 
third,  in  giving  to  the  metal  the  proper  conformation, 
and  in  finishing  the  surface.  The  time  required  for  the 
first,  supposing  the  operation  to  be  like  the  one  just  described,  may 
vary  from  one  and  a  half  to  two  and  a  half  hours  ;  for  the  second,  from 
two  to  three  and  a  half  hours ;  and  for  the  third,  from  two  to  six 
hours,  according  to  the  difficulties  to  be  encountered,  the  ability  of  the 
dentist,  and  the  completeness  of  his  preparation  for  the  operation. 
Some,  perhaps,  may  prefer  crystalline  or  sponge  gold,  supposing  it  to 
be  more  easily  welded  than  cohesive  foil ;  but  as  the  manner  of  working 
this  variety  of  gold  has  already  been  described,  it  will  not  be  necessary 
to  give  additional  directions  for  its  use. 

The  late  Dr.  M.  H.  Webb,  an  expert  operator  in  contour  work, 
gave  the  following  directions  for  completing  such  an  operation  : — 

"  When  the  foil  has  been  prepared  and  impacted  as  described,  and 
so  that  the  substitution  for  the  lost  tissue  is  complete,  a  fine  saw 
or  suitable  file  should  be  used  to  cut  away  the  surplus  material,  and  to 


CONTOUR   FILLINGS.  521 

aid  in  making  the  filling  conform  to  the  original  contour  of  the  part ; 
after  which  narrow  strips  (a  line  or  i-inch  wide)  cut  from  fine  emery 
cloth  should  be  so  manipulated  as  to  properly  form  and  finish  the 
surface  of  the  gold.  When  this  has  been  done,  and  the  rubber  dam 
removed,  the  finishing  should  be  completed  by  the  use  of  fine  pumice 
and  silex  upon  linen  tape,  as  before  suggested.  The  gold  at  the  masti- 
cating surface  should  be  finished  with  fine  burrs,  and  by  their  use  made 
concave,  or  to  conform  to  the  original  type  of  the  part  operated  upon. 
The  gold  should  be  so  impacted  as  to  be  flush  with  the  prepared 
margin  of  enamel ;  yet,  even  then,  made  concave  when  such  concavity 
is  indicated.  Fine  burrs  should  be  used  for  the  purpose  of  trimming 
and  shaping  such  fillings,  because  the  form  of  the  remaining  part  or 
parts  of  the  cusps  and  prepared  edges  of  enamel  against  which  the 
gold  is  placed  may  be  changed,  and  the  teeth  made  less  useful  when 
corundum  cones  are  used.  The  polishing  of  the  gold  upon  the  surface 
referred  to  may  be  done  with  pumice  and  silex,  mounted  upon  suitably 
shaped  points  of  wood,  leather,  or  rubber. 

"  Whether  the  cavity  is  large  or  small,  the  gold  ought  to  be  built 
out  to  the  original  contour  of  the  part,  and  at  its  periphery,  a  little 
beyond  the  margin,  then  finished  down  to  the  surface  of  the  enamel, 
and  the  whole  filling  made  to  conform  to  the  line  that  defined  the 
contour  of  the  lost  tissue.  If  the  gold  be  not  impacted  against  and  be 
not  flush  with  the  edges  of  the  enamel,  the  operation  is  not  such  as  is 
demanded  for  the  preservation  of  remaining  tissues.  A  plane  surface 
of  gold  should  not  De  made,  because  the  tooth  thus  operated  upon,  and 
the  one  adjoining,  may  approximate  closely,  and  disintegration  of 
enamel  take  place  near  or  at  the  part  in  contact.  Restoration  of 
contour  prevents  such  contact,  and  this  prevention  is  necessary, 
especially  when  the  tissues  of  the  organ  operated  upon  are  not  fully 
calicified.  When  operations  have  been  so  performed  as  to  entirely 
prevent  fluids  or  semi-solids  from  entering  between  gold  and  the  tissue 
against  which  it  has  been  placed,  the  gold  tint  may  be  seen  through  the 
light  walls  or  edges  of  translucent  enamel  soon  after  the  removal  of  the 
rubber  dam  and  completion  of  the  operation.  If  an  opaque  or  dark 
line  or  spot  be  visible  at  or  near  the  parts  where  gold  ought  to  be  in 
contact  with  dentine  and  enamel,  the  operation  has  been  imperfectly 
performed,  and  chemical  action  may  soon  fi^llow  and  the  entire  filling 
prove  a  failure." 

The  operation  of  building  on  the  entire  crown  of  a  tooth  should  be 
proceeded  with  much  in  the  same  way  as  just  described  for  part  of  the 
crown.  If  too  large  pieces  of  either  crystal  gold  or  fiail  are  used  at 
one  time,  the  surface  will  become  crusted  over  by  the  pressure  of  the 
point  of  the  instrument,  and  this  will  prevent,  by  any  subsequent  force 


522  DENTAL    SURGEEY. 

that  can  be  safely  applied,  its  thorough  consolidation.  In  this  case, 
the  general  mass  will  be  more  or  less  spongy  and  the  operation 
imperfect.  The  dentist  should  be  well  assured,  therefore,  as  he  pro- 
gresses with  his  work,  that  every  successive  layer  is  firmly  adherent  to 
the  preceding  one.  To  build  up  an  entire  crown  requires  more  time  ; 
perhaps,  also,  more  skill,  as  there  is  no  wall  of  tooth  substance  to  give 
partial  support.     In  other  respects  it  resembles  the  previous  operation. 

Ifc  has  been  suggested  by  Prof.  Austen,  as  a  plan  to  avoid  much  of 
the  tediousness  of  the  second  stage  of  this  operation,  to  fill  the  pulp 
cavity,  inclosing  in  the  centre  a  screw-cut,  notched,  or  double-headed 
pin,  and  carrying  the  gold  over  the  edges  of  the  cavity  ;  make  this 
surface  somewhat  irregular  in  shape,  but  finish  it  smoothly,  and  trim 
the  circumference  to  the  exact  size  of  the  tooth  ;  take  a  wax  or  plaster 
impression  of  the  surface,  and  fit  to  the  plaster  model  a  lump  of  gold, 
having  in  the  centre  a  hole  larger  than  the  pin  projecting  from  the 
root ;  shape  and  polish  it  out  of  the  mouth,  then  set  it  in  place  and 
secure  it  by  filling  with  gold  around  the  pin.  If  the  color  is  not 
objected  to,  a  vulcanite  crown  could  be  very  perfectly  adapted  in  this 
manner ;  or  a  porcelain  tooth  could  be  made,  hollow  in  the  centre, 
with  pins  or  a  dovetail  to  hold  a  thin  layer  of  vulcanite,  by  means  of 
which  it  could  be  fitted  with  perfect  accuracy  to  the  prepared  root. 
Prof.  Austen  thinks  that  in  this  way  the  root  will  be  less  injured,  and 
the  union  between  the  gold  and  the  root  less  disturbed  than  by  the 
long-continued  and  severe  pressure  of  the  ordinary  operation.  While 
the  artificial  crown  is  being  made,  he  suggests  a  temporary  gutta- 
percha crown  to  prevent  any  irritation  from  the  projecting  pin. 

A  large  portion  of  the  crown  of  a  tooth  may  be  built  up  with 
ordinary  gold  foil,  if  it  be  of  the  best  quality;  but  the  cohesive 
preparations,  either  foil  or  crystal  gold,  are  preferable.  It  was  formerly 
considered  to  be  much  more  difficult  to  build  up  the  crown  of  a  tooth 
in  the  lower  than  in  the  upper  jaw,  owing  to  the  great  difficulty  of 
controlling  the  flow  of  saliva  during  so  long  an  operation.  But  by  the 
use  of  the  appliances  before  referred  to,  this  difficulty  is  now  almost 
entirely  obviated. 

"NYe  have  endeavored,  in  the  foregoing  description,  to  point  out  the 
general  method  of  procedure  in  the  operation  of  which  we  have  been 
treating.  We  have  also  noticed  some  of  the  precautions  necessary  to 
be  observed  ;  but  unexpected  difficulties  are  sometimes  encountered, 
the  peculiar  nature  of  which  it  is  impossible  to  anticipate.  Few, 
however,  are  of  so  formidable  a  character  that  they  cannot  be  over- 
come. 

During  the  operation  of  building  up  a  portion  or  the  whole  of  a 
crown  with  cohesive  gold,  if,  in  condensing  it,  any  part  becomes  dis- 


CONTOUR    FILLINGS. 


523 


placed  or  fails  to  unite  with  that  already  introduced,  it  should  be 
removed,  otherwise  the  filling  will  prove  defective ;  and  this  rule  will 
apply  to  all  fillings  of  this  form  of  gold.  Each  piece,  as  it  is  intro- 
duced, must  be  firmly  attached  to  that  already  in  position,  and  no 
doubt  should  exist  concerning  secure  anchorage.  When  a  contour 
filling,  which  includes  a  portion  or  the  whole  of  the  masticating  sur- 
face of  a  bicuspid  or  molar,  has  been  properly  inserted  and  the  gold 
built  up  flush  with  the  margins  of  enamel,  such  a  surface  should  be 
made  to  correspond  to  the  original  surface  in  form,  by  making  it  con- 
cave by  means  of  the  fine  finishing  burrs  or  corundum  points  used 
with  the  dental  engine,  when  it  may  be  polished  with  pumice  and  silex, 
applied  by  properly-shaped  points  of  wood,  rubber  or  leather.  In  all 
such  building  up,  the  gold  should  be  carried  beyond  the  margin  and 
then  cut  down  to  the  surface  of  the  enamel,  preserving  the  original 
contour  of  the  part  as  much  as  is  possible.  By  the  aid  of  Dr.  Jack's 
matrices  (Fig.  341)  the  contouring  of  approximal  surface  cavities, 
especially  posterior  ones,  is  greatly  facilitated,  as  they  enable  the 
operator  to  adapt  and  impact  the  gold  in  a  perfect  manner. 

To  retain  the  gold  of  contour  fillings  in  large,  saucer-shaped  and 
other  forms  of  cavities,  screws,  made  of  fine  gold,  securely  anchored 
in  the  dentine,  with  free  ends  projecting  above  the  surface  around 
which  the  gold  is  built,  are  available. 

Fig.  347  represents  Dr.  How's  Retaining  Screws  and  instruments 
for  their  introduction.  A  shows  a  cone-socket  screw-driver  with  a 
sliding  split  tube  which  serves  as  an  ad- 
justable holder  for  the  screw,  in  the  end  of 
which  is  a  slot,  such  as  the  operator  may 
readily  cut  with  a  No.  5  separating  file. 
On  placing  the  screw  in  the  holder  the 
driver  blade  will  enter  the  slot  as  shown 
in  partial  section  by  B.  C  shows  in  its 
palatal  aspect  an  incisor  wherein  the 
apical  portion  of  the  pulp  chamber  has 
been  properly  filled  and  the  main  portion 
drilled  and  tapped  with  an  A  tap  and 
drill.  The  tap  is  so  set  in  the  tap-chuck 
as  to  be  a  gauge  by  which  the  screw-post 
may  be  cut  as  much  shorter  than  the 
gauge  as  will  let  the  screw,  after  it  has 
been  placed  in  the  holder  (see  B)  and 

carried  to  its  place  in  the  root,  project  as  shown  in  C.  D.  shows  a 
molar,  in  the  palatal  root  of  which  a  B  screw  has  been  likewise  in- 
serted.     It  is  obvious  that   large  contour   fillings  may   be   securely 


Fig.  347. 


524 


DEXTAL   SURGERY. 


built   around    screw-posts   thus   firmly   fixed   in    the   roots   of   such 
teeth. 

Fig.  348  represents  Dr.  E.  Osmond's  screws  for  securing  gold  fillings, 
with  the  instruments  necessary  for  their  introduction. 


Fig.  348. 


A  A  are  screws  made  of  20-earat  gold  wire,  annealed,  split  about 
half-way,  once  or  twice,  so  as  to  form  two  or  four  arms  when  opened. 
B  is  a  screw-driver,  surrounded  by  a  tube  for  the  purpose  of  holding 
the  screw  and  carrying  it  to  its  place  in  the  tooth.  C  is  a  drill,  for 
the  purpose  of  drilling  a  hole  which  is  afterward  tapped  by  the  tap- 
screw  D. 

Figs.  1  and  2  are  teeth  with  large  saucer-shaped  cavities,  such  as  we 
very  frequently  find  ;  but  other  cases  in  which  these  screws  are  avail- 
able will  readily  suggest  themselves  to  the  mind  of  the  experienced 
operator. 

Fig.  349  represents  the  instruments  for  manipulating  what  is  known 
as  the  St.  Louis  System  of  Retaining  Screws. 

In  this  set  of  instruments  the  drills,  taps  and  wire  fitted  for  each 
other  bear  corresponding  numbers,  as  1,  2,  3. 

The  wire-holder  is  made  adjustable  to  take  either  size  of  wire. 

The  cutting  edges  of  the  cutting  pliers  are  formed  with  two  round 
openings,  as  shown  in  the  cut.  The  long  wire  to  be  used,  if  put  in 
one  of  the  openings,  can  be  "  nicked  "  at  the  proper  distance  to  form 
the  screw  while  in  the  wire-holder,  so  that,  after  having  been  screwed 
into  place,  it  may  readily  be  broken  off,  without  the  use  of  file  or 
pliers  in  the  mouth. 

Under  the  head  of  "  Contour  Work  "  reference  may  be  made  to  the 
use  of  forms  of  porcelain,  as  shown  in  Fig.  350,  for  filling  cavities 
of  decay. 


CONTOUR   FILLINGS. 
Fig.  349. 


525 


526 


DENTAL   SURGERY 


Fir; 


These  are  to  be  used  in  conjunction  with  oxychloride  or  oxyphos- 
phate  of  zinc,  gutta-percha,  and  may  be  set  in  amalgam,  though  this 

material  is  objectionable,  because 
of  shrinkage.  Used  on  an  articu- 
lating surface,  they  have  the  advan- 
tage of  a  hardness  at  least  equal  to 
the  most  solid  metal  filling.  They 
may  also  be  used  to  avoid  the  dis- 
play of  more  noticeable  filling  ma- 
terial. 

For  what  is  commonly  called 
"  bridge-work,"  the  reader  is  re- 
ferred to  the  article  on  "Prepara- 
tion of  a  Natural  Koot  and  Attach- 
ment of  an  Artificial  Crown." 

Fig.  351  represents  Dr.  B.  J. 
Bing's,  method  of  capping  a  carious 
or  broken  tooth.  It  consists  in 
properly  preparing  the  walls  of 
the  cavity,  and  taking  an  im- 
pression of  it  with  wax  or  modeling 
composition.  Dies  are  thus  obtained,  upon  which  gold  caps  are  struck 
up.  Small  loops  or  rings  are  soldered  to  the  bottom  of  the  caps,  which 
are  secured  in  the  cavities  by  gutta-percha  or  oxyphosphate  of  zinc. 

Fig.  352. 


Fig.  352  represents  a  Three-tray  Student's  Case  suitable  for  an  outfit 


CONTOUR    FILLINGS. 


527 


of  operative  instruments,  a  set  of  which  may  consist  of  a  limited 
number  of  instruments,  such  as  Pluggers,  Chisels,  Scalers,  Foil  Carrier 
and  Plugger  combined,  Excavators,  Dental  Engine  Instruments,  Pulp- 
cavity  Pluggers,  Drills  and  Extractors,  Files,  Syringe,  Arkansas 
Stone,  Foil  Shears,  Foil  Folder,  Mouth  Mirror,  Rubber  Dam,  Rubber- 
Dam  Holder,  Rubber-Dam  Clamps,  Rubber-Dam  Clamp  Forceps, 
Automatic  Mallet,  Chamois  Skin,  Orange  Wood,  Linen  Tape,  Bur- 
nisher. The  heavy  and  expensive  instruments,  such  as  the  Dental 
Engine,  Extracting  Forceps  and  Dental  Chair  are  usually  furnished 
by  the  dental  schools.  The  following  illustration  represents  one  of 
the  most  popular  Dental  Chairs  in  use  at  the  present  time,  and  which 
combines  all  of  the  different  movements  required  by  the  dental 
practitioner  : — 

Fig.  353. 


The  Wii.KERSON  Dental  Chair. 


528  DENTAL   SURGERY. 


CHAPTER  III. 

FILLING   TEETH   OVER   EXPOSED   PULPS. 

THE  pulps  of  the  teeth  may  be  exposed  by  mechanical  injuries  and 
caries  ;  the  first  may  occur  from  falls,  blows,  the  careless  excava- 
tion of  carious  cavities  by  means  of  the  engine-burr  or  the  excavator, 
while  the  latter  is  the  result  of  the  destruction  and  disintegration  of 
the  tooth  structure  to  such  a  degree  as  to  expose  the  organ,  which 
becomes  irritated  as  a  consequence,  and,  if  the  irritation  is  continued, 
leads  to  its  suppuration,  ulceration  and  death.  The  propriety  of  filling 
a  tooth  after  the  invasion  of  the  pulp  cavity  by  caries,  without  first 
destroying  the  pulp,  was  for  a  long  time  doubted  by  many  practitioners. 
It  was  thought  that  inflammation  and  suppuration  of  the  pulp  must 
necessarily  result  from  the  operation.  But  Dr.  Koecker,  who  was  the 
first  to  recommend  filling  a  tooth  under  such  circumstances,  cited  a 
number  of  cases  in  which  he  performed  the  operation  successfully.  He 
also  expressed  the  belief  that  "  on  an  average,  five  out  of  six  teeth  may 
be  preserved  alive,  and  rendered  useful  for  a  long  while." 

Admitting  the  fact,  which  is  now  daily  demonstrated,  that  teeth  can 
be  preserved  alive  after  the  pulp  has  become  partially  or  wholly 
exposed,  the  question  arises,  Does  the  pulp  remain  in  the  condition  in 
which  it  is  at  the  time  the  operation  is  performed  ?  It  is  difficult  to 
conceive  either  how  a  vacant  space  can  exist  between  it  and  the  filling, 
or  how  a  foreign  body  can  remain  in  contact  with  it,  with  impunity. 
The  late  Drs.  Harwood,  of  Boston,  and  J.  H.  Foster,  of  New  York, 
and  also  Dr.  W.  H.  Dwindle,  held  the  opinion,  from  experiments  they 
had  made,  that  it  ossifies.  That  some  change  of  this  nature  does  take 
place  is  well  known,  and  the  transition  is  evidently  the  result  of 
increased  vascular  action  caused  by  irritation.  Examples  of  such 
ossification  are  met  with  in  teeth  in  which  the  crowns  have  lost  a 
considerable  portion  of  their  substance  from  mechanical  or  spontaneous 
abrasion ;  and  it  is  a  beautiful  provision  of  nature  to  prevent  the 
exposure  of  these  delicate  and  highly  sensitive  parts.  The  same  thing 
sometimes  occurs  in  teeth  which  have  sufieredno  loss  of  substance,  and 
is  doubtless  the  result  of  some  constitutional  or  local  cause  of  irritation. 

These  facts  would  seem  to  justify  the  conclusion,  elsewhere  stated, 
that  the  pulp  of  a  tooth,  when  subjected  for  a  sufficient  length  of  time 
to  the  influence  of  an  irritating  agent,  capable  of  exciting  only  a  very 
light  inflammatory  action,  undergoes  ossification ;  or  rather  is  converted 


FILLING    TEETH    OVER    EXPOSED    PULPS.  529 

into  a  substance  resembling  crusta  petrosa,  or  what  Prof.  Owen  terms 
osteo-dentine.  A  tooth  which  has  been  filled  after  the  pulp  has  become 
exposed,  is  liable,  when  it  fails  to  undergo  this  change,  either  to  perish, 
from  derangement  of  its  nutritive  functions,  or  to  become  the  seat  of 
active  inflammation  and  suppuration.  But  something  more  than  ossi- 
fication, or  conversion  into  osteo-dentine,  takes  place  when  a  space  is 
left  between  it  and  the  filling.  If  this  vacant  space  were  not  filled  up,  we 
have  reason  to  believe  that  the  slightest  increase  of  vascular  action 
would,  as  has  been  justly  remarked  by  Dr.  Elliot,  force  a  portion  of 
the  pulp  into  it ;  and  thus  active  inflammation  would  be  excited  by 
contact  with  the  sharp  angles  of  the  walls  of  the  cavity,  and  this,  as  .a 
natural  consequence,  would  be  apt  to  terminate  in  suppuration  ; 
consequently,  the  capping  should  be  adapted  as  nicely  as  possible  to  the 
exposed  surface,  leaving  no  intervening  space. 

When  this  reparative  process  does  not  take  place  after  the  operation, 
it  may  be  owing  either  to  want  or  the  excess  of  vascular  action  in  the 
lining  membrane  or  pulp.  A  certain  amount  of  increased  vascular 
action  seems  necessary  to  the  effusion  of  coagulable  lymph,  an  indis- 
pensable requisite ;  but  when  this  is  too  great,  it  must  of  necessity 
terminate  in  suppuration.  It  is  obvious,  therefore,  that  the  success  of 
the  operation  must  very  greatly  depend  upon  the  circumstances  under 
which  it  is  performed.  If  these  be  unfavorable,  all  efforts  to  preserve 
the  vitality  of  the  organ  will,  in  a  majority  of  cases,  prove  unavailing, 
however  skillful  the  operator  may  be  in  the  preparation  of  the  cavity 
and  the  introduction  of  the  gold.  The  health  of  the  patient  should  be 
unimpaired';  the  tooth  of  a  tolerably  good  quality,  free  from  pain  at 
the  time  the  operation  is  performed ;  and  the  pulp,  peridental  mem- 
brane and  surrounding  parts  should  be  in  a  perfectly  healthy  condition. 
The  cavity  should  be  of  a  proper  shape  for  the  easy  introduction  and 
permanent  retention  of  the  filling ;  and  the  smaller  the  point  of 
exposure  of  the  lining  membrane,  the  greater  the  prospect  of  success. 
It  is  also  important  that  every  particle  of  completely  decomposed 
dentine  be  removed,  and  if  there  be  any  oozing  of  blood  from  the 
ruptured  vessels,  this  must  cease  before  the  filling  is  introduced. 

The  direct  application  of  any  metallic  substance  to  the  pulp  is, 
according  to  the  observation  of  the  author,  very  apt  to  be  followed  by 
inflammation  and  suppuration  of  these  tissues.  Some  of  the  vessels  of 
the  pulp  may  be  wounded  in  removing  the  last  layer  of  decomposed 
dentine,  but  the  hemorrhage,  when  no  other  injury  is  inflicted,  is  very 
slight,  and  sometimes  scarcely  perceptible  ;  so  that  the  operation  of 
filling  need  never  be  delayed  more  than  from  three  to  ten  minutes.  The 
application  of  a  small  particle  of  cotton  moistened  with  spirits  of  cam- 
phor, or  a  solution  of  tannin,  or  a  little  carbolic  acid,  will  usually  arrest  it. 

34 


530  DENTAL   SURGERY. 

The  late  Dr.  Koecker  suggested  the  direct  application  of  a  piece  of 
leaf  lead,  and  the  late  Dr.  S.  S.  Fitch  a  plate  of  gold,  as  cappings  for 
exposed  pulps.  Later,  Dr.  J.  H.  Foster,  of  New  York,  suggested  a 
cap  of  gold,  the  concave  surface  of  which  was  filled  with  gutta-percha, 
but  allowing  a  space  between  the  concave  surface  of  the  cap  and  the 
point  of  exposure,  the  object  of  the  gutta-percha  being  to  protect  the 
pulp  from  heat  and  cold.  This  method  of  Dr.  Foster's  was  claimed  to 
be  successful  in  a  number  of  cases,  but  the  introduction  of  substances 
better  adapted  as  capping  materials,  at  a  later  date,  has  been  attended 
with  greater  success  in  such  delicate  operations. 

The  zinc  preparations  have  been  extensively  employed  of  late 
years  to  cap  exposed  and  partially  exposed  pulps.  The  oxychloride 
of  zinc,  owing  to  its  irritant  action,  should  never  be  placed  in  direct 
contact  with  the  pulp  of  a  tooth  ;  hence  such  substances,  in  the  form 
of  thin  disks,  as  oiled  paper,  oiled  silk,  vellum,  platinum  caps,  softened 
quill,  and  horn  have  been  used  as  interposing  materials. 

It  is  the  practice  of  some  to  coat  the  surface  of  such  disks  in  contact 
with  the  pulp  with  a  solution  of  gutta  percha  and  chloroform,  which 
acts  as  a  non-conducting  substance,  and  is  tolerated  by  the  sensitive 
organ,  owing  to  its  anodyne  and  protective  properties.     The  inter- 
posing substance  may  be  held  in  place  within  the  cavity  by  a  delicate 
excavator  or  nerve  instrument  and  the  oxychloride,  of  thin  consistency, 
flowed  over  it,  when  the  remaining  portion  of  the  cavity  can  be  filled 
with  the  same  material  in  the  form  of  a  thicker  paste.     A  portion  of 
this  material  is  afterwards  removed,  for  the  accommodation  of  a  more 
permanent  filling.     The  employment  of  the  oxyphosphate  of  zinc  as  a 
capping  for  exposed  pulps  has  given  more  satisfaction  than  the  oxy- 
chloride, owing  to  its  less  irritating  action  ;  and  the  practice  of  many  is 
to  apply  it,  in  the  form  of  a  thin  paste,  directly  to  the  exposed  surface. 
Gutta-percha,  in  the  form  of  Hill's  stopping,  is  also  used  with  success  as 
a  capping  material,  a  very  thin  disk,  which  becomes  plastic  at  a  low 
temperature,  being  first  applied,  so  that  the  effect  of  the  heat  may 
be    reduced   to   a    minimum.       Asbestos,  either    alone   or    enclosed 
between  layers  of  gold  or  tin  foil,  has  also  been  employed  as  a  cap- 
ping, concave  disks  being  formed  when  metal   is  used  in  combina- 
tion with  the  asbestos,  the  inner  surfaces  of  which  are  coated  with  the 
solution  of  gutta-percha  and  chloroform.     Thin  cardboard  paper,  in 
the  form  of  caps  saturated  with  carbolic  acid,  has  also  been  employed 
as  an  interposing  substance  between  the  point  of  exposure  and  a  filling 
of  the  zinc  preparation.     Dr.  W.  C.  Barrett   has  been  successful  in 
capping   exposed  pulps   with    the   lactophosphate  of  lime,  which  is 
applied  as  an  immediate  cover  to  the  exposed  tissue,  and  which  is  pre- 
pared as  follows  :  on  a  piece  of  glass  or  porcelain  is  placed  a  drop  of 


FILLING    TEETH    OVER   EXPOSED    PULPS.  531 

Merck's  lactic  acid,  to  which  as  much  magma  phosphate  is  added  as 
it  will  digest ;  it  is  then  reduced  to  the  proper  consistency  by  adding 
the  dry  precipitated  phosphate.  The  magma  phosphate  must  be  kept 
under  water.  It  has  been  found  that  the  lactophosphate  of  lime,  pre- 
pared as  above,  is  very  congenial  to  the  pulp. 

Dr.  King's  method  of  capping  exposed  pulps  is  as  follows :  A 
temporary  filling  of  the  oxychloride  or  the  oxyphosphate  of  zinc  is 
placed  over  the  capping ;  the  rubber  daiii  being  applied  in  all  cases 
previous  to  the  excavation  of  the  crown  cavity.  Pure  wood  creasote 
is  mixed  with  pure  oxide  of  zinc,  to  the  consistency  of  cream,  when  it  is 
flowed  over  the  exposed  surface.  Oxychloride  or  oxyphosphate  of 
zinc,  mixed  to  the  same  consistency,  is  placed  over  the  capping  of  the 
creasote  and  oxide  of  zinc,  and  allowed  to  remain  for  a  few  days,  when 
a  portion  of  the  temporary  filling  is  removed  and  a  more  durable  one 
inserted. 

Although  bathing  the  exposed  surface  of  the  pulp  with  pure  carbolic 
acid  is  practiced  by  many  prominent  dental  practitioners,  others  con- 
tend that  the  escharotic  action  of  the  agent  may  prove  injurious,  and 
hence  use  either  a  diluted  form,  or  the  pure  crystallized  carbolic  acid 
rendered  fluid  by  a  small  quantity  of  chloroform.  It  is  very  essential, 
in  the  treatment  of  cases  of  exposure  of  the  pulp,  that  a  due  regard  be 
paid  to  the  condition  of  the  organ,  and  the  diflference  between  normal 
and  abnormal  sensitiveness  determined.  If  it  is  a  case  of  simple  expo- 
sure, after  carefully  preparing  the  crown  cavity,  and  the  margin  of  the 
opening  leading  to  the  pulp,  after  syringing  with  tepid  water,  all 
moisture  should  be  carefully  removed,  and  a  drop  of  the  solution  of 
gutta  percha  dissolved  in  chloroform  applied  on  the  point  of  a  delicate 
instrument  (some  prefer  dilute  tincture  of  aconite,  or  a  thin  coating  of 
glycerine  or  collodion),  and  the  cavity  filled  temporarily  with  wax  or 
cotton,  the  tooth  remaining  at  rest  for  a  few  days  and  protected  from 
irritation. 

When  everything  has  progressed  favorably  for  such  a  period,  the 
operation  of  capping  may  be  performed.  Should  the  pulp  be  irritable, 
or  the  seat  of  acute  pain  when  first  examined,  the  cavity  should  be 
syringed  out  with  tepid  water  containing  a  sufficient  quantity  of  car- 
bonate of  soda  to  render  the  solution  slightly  alkaline.  Such  an  appli- 
cation will  relieve  the  pain,  even  if  it  is  acute.  The  application  of  lead 
water  is  often  useful  for  the  same  purpose,  or  the  dilute  tincture  of 
aconite,  or  a  solution  of  the  sulphate  of  atropine. 

Professor  James  H.  Harris  recommends  the  following  method  of 
treating  teeth  with  exposed  pulps:  "First,  remove  all  decomposed 
dentine,  for  if  any  dentine  in  such  a  condition  is  allowed  to  remain, 
the  progress  of  decay  will  continue  and  cause  inflammation  of  the 


632  DENTAL,  SURGERY. 

pulp,  finally  resulting  in  its  destruction.  Even  if  the  carious  portion 
is  entirely  removed  and  the  pulp  not  directly  exposed,  we  still  need  nat 
be  too  confident  of  the  ultimate  preservation  of  the  vitality  of  the 
tooth,  for  the  probability  is  that  the  dentinal  fibrillse  die  in  advance  of 
the  actual  decomposition  of  the  tooth  substance,  and  hence,  before  the 
decay  has  actually  reached  the  pulp,  this  organ  may  have  assumed  a 
condition  from  which  recovery  is  impossible.  Still,  however,  every 
attempt  should  be  made  to  preserve  the  vitality  of  the  pulps  of  the 
teeth,  and  with  this  object  in  view,  having  removed  all  of  the  decay, 
should  any  hemorrhage  occur,  it  may  be  arrested  with  spirits  of 
camphor,  or  with  camphor  and  tincture  of  opium.  The  entire  crown 
cavity  should  now  be  carefully  filled  with  a  temporary  filling  of  Hill's 
stopping,  avoiding  undue  pressure  upon  the  pulp.  The  first  piece  of 
the  Hill's  stopping  may  be  more  safely  adapted  by  first  moistening  it 
with  chloroform. 

"  This  temporary  filling  should  be  removed  from  time  to  time,  as 
may  be  necessary,  during  a  period  of  from  one  to  five  years,  according 
to  the  health  of  the  patient,  extent  of  exposure,  etc.  With  this  treat- 
ment, the  reparative  process  will  more  readily  go  on,  and  Avhen  the 
pulp  is  found  to  have  become  protected  by  a  layer  of  osteo-dentine,  a 
permanent  metallic  filling  may  be  inserted. 

"  As  a  further  precaution  against  danger  to  the  pulp,  a  layer  of 
Hill's  stopping,  or  of  oxyphosphate  of  zinc  may  be  placed  in  the 
bottom  of  the  cavity,  and  the  permanent  filling  inserted  over  this. 
Sometimes,  Avhen  the  exposure  is  quite  large,  it  will  be  found  well  to 
cap  the  pulp  with  a  thin  mixture  of  oxyphosphate  of  zinc,  as  this 
material  can  be  more  readily  adapted  to  the  exposed  pulp  without 
danger  of  producing  undue  pressure.  But  even  when  this  method  is 
pursued,  it  is  best  to  first  coat  the  exposed  surface  of  the  pulp  with  a 
solution  of  gutta-percha  and  chloroform,  in  order  to  protect  it  from  the 
slightly  irritant  effect  of  the  oxyphosphate.  The  oxyphosphate  first 
introduced  should  be  mixed  thin,  and  allowed  to  harden,  when  the 
remainder  of  the  cavity  should  be  filled  with  the  same  material  mixed 
stiffer,  especially  when  the  cavity  involves  the  grinding  surface,  where 
a  portion  of  the  filling  is  subjected  to  the  friction  of  mastication. 
Sometimes,  in  large  grinding  surface  cavities,  after  capping  and  filling 
the  cavity  two-thirds  full  of  Hill's  stopping  or  oxyphosphate,  the 
filling  may  be  finished  with  amalgam,  which  is  permitted  to  remain  as 
a  test-filling  for  from  three  to  six  months,  when,  if  no  symptoms  of 
pulpitis  manifest  themselves,  such  as  paroxysms  of  pain  caused  by  heat 
and  cold,  and  gradually  becoming  constant,  a  portion  of  the  temporary 
filling  (about  one-third)  may  be  removed,  and  the  cavity  filled  with 
amalgam,  which  is  allowed  to  remain,  as  before  stated,  from  one  to  five 


FILLING    TEETH    OVER    EXPOSED    PULPS.  533 

years.  Then  the  amalgam  may  be  removed,  and,  if  necessary  for  the 
support  of  the  gold  to  be  substituted,  a  small  portion  of  the  Hill's 
stopping  or  the  oxyphosphate,  and  a  gold  filling  inserted.  In  remov- 
ing the  temporary  filling,  preparatory  to  inserting  a  gold  filling,  the 
condition  of  the  dentine  should  be  carefully  noted — whether  it  is 
normally  sensitive  or  not,  as  the  pulps  of  teeth  often  die  from  chronic 
inflammation  without  pain  to  the  patient,  in  which  case  the  dentine 
would  be  devoid  of  sensitiveness.  Ossification  of  a  pulp  renders  the 
dentine  painless.  During  the  removal  of  a  portion  of  the  temporary 
filling,  should  the  dentine  be  found  not  sensitive,  the  operation  of 
removing  the  temporary  filling  should  be  continued  until  the  cause  of 
such  want  of  sensation  be  ascertained,  whether  to  the  death  of  the 
pulp  or  its  ossification. 

"  In  performing  the  operation  of  '  capping,'  the  rubber-dam  should 
be  applied,  if  possible. 

"  In  the  treatment  of  cases  of  exposure  of  the  pulp  a  careful  record 
should  always  be  kept,  as  it  is  impossible  to  remember  the  peculiarities 
of  each  case  extending  through  a  long  period  of  treatment." 

The  following  method  of  treating  exposed  pulps  was  recommended 
by  the  late  Dr.  M.  H.  Webb  :— 

"If  irritation  of  the  pulp  be  caused  by  the  acid  condition  concomi- 
tant with  the  disintegration  process,  it  should  subside  after  tepid  salt 
water  has  been  injected,  and  the  parts  thus  cleansed,  the  softer  portions 
of  carious  dentine  removed,  and  bicarbonate  of  soda,  potash  or  am- 
monia applied.  Should  the  exposed  or  nearly  exposed  tissue  be 
impinged  upon  by  the  carious  dentine,  or  a  foreign  substance,  which 
has  been  forced  during  mastication  upon  it,  and  thus  obstruct  the 
nutrient  currents,  the  irritation  thus  induced  should  cease  after  the 
removal  of  the  agent  which  causes  the  obstruction.  When  the  pain 
has  ceased  the  parts  should  be  dried  with  Japanese  bibulous  paper ;  an 
application  of  carbolic  acid  should  be  made  to  disinfect  the  disinte- 
grated dentine  which  may  yet  remain  and  coagulate  the  protoplasm 
at  the  exposed  part  of  the  pulp,  if  there  be  such  exposure.  After  this 
has  been  done,  a  cap  of  note  paper  or  fine  card  board  should  be  placed 
over  the  nearly  or  fully  exposed  part  of  the  pulp,  so  that  it  be  not 
pressed  upon  during  the  insertion  of  gutta-percha  ;  all  of  which  is  but 
preparatory  treatment.  After  the  cavity  has  been  thus  cleansed,  the 
pulp  protected  and  ease  secured,  the  rubber  dam  should  be  applied, 
the  temporary  filling  removed,  light  reflected  upon  the  parts  by  a 
mouth  mirror,  and  all  decalcified  tissue  cut  away,  excepting  the  dis- 
colored or  partially  disintegrated  dentine,  which  may  yet  cover  the 
pulp,  such  a  protection  being  very  much  better  than  an  artificial  one. 
When  all  this  shall  have  been  done,  warm  air  should  be  used  to  drive 


534  DENTAL  SURGERY. 

off  the  moisture  (as  well  as  to  expel  the  chippings)  which  may  yet  be 
in  the  cavity  and  on  the  discolored  dentine ;  then  the  latter  should  be 
moistened  with  carbolic  acid  or  a  saturated  solution  of  salicylic  acid 
in  alcohol.  Where  the  pulp  is  nearly  or  partly  exposed,  it  is  best 
to  flow  carbolic  acid  over  the  part,  and,  before  evaporation  follows, 
take  some  of  the  oxide  of  zinc  on  the  end  of  a  small  spatula;  place  it 
at  the  entrance  to  the  cavity,  and,  with  a  puff*  of  warm  air,  spread  it 
over  and  about  the  exposure,  there  to  be  retained  by  the  deliquescent 
carbolic  acid.  After  this  has  been  done,  one  of  the  preparations  of 
oxychloride  of  zinc  (the  oxyphosphate  may  now  answer  better)  "should 
be  mixed  to  the  consistency  of  thick  cream,  and  made  to  flow  down 
one  side  of  the  cavity,  over  the  layer  of  oxide  of  zinc,  and  carbolic 
acid  (or  pure  wood  creasote),  and  along  the  whole  surface  of  the  den- 
tine, and  to  the  outer  margin  of  the  enamel.  The  rubber  dam  ought 
not  to  be  removed  for  about  an  hour  after  the  oxychloride  (or  oxyphos- 
phate) of  zinc  has  been  placed  in  the  cavity,  because  a  more  perfect 
crystallization  of  the  cement  takes  place  when  it  is  dry.  These  cases 
should  be  kept  in  this  condition  for  some  time  (in  some  cases  a  year  or 
more)  before  the  permanent  filling  is  inserted,  although,  under  favor- 
able conditions,  the  operation  may  be  proceeded  with  immediately  or 
very  soon  after  the  oxychloride  of  zinc  has  crystallized ;  but  whenever 
this  operation  is  to  be  performed,  only  enough  of  the  cement  should 
be  removed  to  secure  proper  and  sufficient  anchorage  for  the  gold." 

In  using  creasote  or  carbolic  acid  in  combination  with  the  oxide  of 
zinc,  the  excess  of  the  fluid  can  be  removed  with  spunk,  thus  leaving 
a  thin  layer  only,  to  prevent  the  pulp  from  being  brought  in  direct 
contact  with  the  zinc  preparation. 

As  the  oxyphosphate  and  oxychloride  are  not  non-conductors,  it 
has  been  suggested  to  place  a  thin  layer  of  gutta-percha  over  them,  to 
protect  the  tooth  from  thermal  changes. 

In  cases  of  long  exposure  it  has  been  recommended  to  wash  out  the 
cavity  with  a  warm  solution  of  salt  and  water,  for  its  sedative  effect, 
or  of  carbonate  of  soda  ;  then  to  apply  creasote  on  a  pledget  of  cotton, 
over  which  a  temporary  filling  of  Hill's  stopping  is  placed,  to  remain 
for  one  or  two  days ;  then  to  remove  the  temporary  filling,  and,  if  no 
pain  has  been  experienced,  to  cap  the  pulp,  as  in  a  case  of  more  recent 
exposure. 

Where  it  is  desirable  to  cap  the  pulps  of  the  temporary  teeth,  and 
the  oxyphosphate  of  zinc  cannot  be  employed,  owing  to  its  irritating 
action  on  the  sensitive  tooth  structure,  a  convex  cap  of  platinum,  the 
concavity  of  which  is  filled  with  the  solution  of  gutta-percha  and  chloro- 
form, may  be  applied  in  such  a  manner  as  to  avoid  pressure,  and  a  Hill's 
stopping  filling  inserted  over  the  cap. 


FILLING   PULP  CHAMBERS    A.ND   CANALS   OF   TEETH.        535 


CHAPTER  IV. 

FILLING   PULP    CHAMBERS   AND     CANALS   OF    TEETH. 

THIS  operation  has  now  become  very  common,  and  is  practiced  by 
the  most  skillful  dentists  in  America  and  in  Europe,  although  its 
propriety  was  for  a  long  time  doubted  by  many.  The  objection  to  the 
practice  was  founded  upon  the  supposition  that,  in  proportion  as  the 
vitality  of  the  tooth  is  lessened  it  becomes  obnoxious  to  the  surround- 
ing living  parts. 

It  was  contended  that,  though  the  presence  of  the  tooth  may  not 
give  rise  to  alveolar  abscess,  it  is  to  some  extent  a  local  irritant ;  that 
as  such  it  must  necessarily  exert  a  morbid  influence,  not  only  upon  the 
living  parts  with  which  it  is  in  immediate  contact,  but  also  upon  the 
whole  economy.  Hence  it  was  argued  that  the  proper  remedial  indi- 
cation, after  the  death  of  the  lining  membrane,  is  the  extraction  of  the 
tooth.  This  reasoning,  it  must  be  admitted  by  all  who  have  any 
knowledge  of  the  laws  of  health  and  disease,  is  not  without  much 
seeming  plausibility.  Until  within  a  comparatively  recent  period,  the 
result  of  most  of  the  efforts  made  for  the  preservation  and  retention 
of  teeth  in  this  condition  fully  justified  its  supposed  correctness ;  for, 
in  nine  cases  out  of  ten,  the  operation  of  filling,  unless  an  opening 
was  left  for  the  escape  of  matter  secreted  at  the  extremity  of  the 
root,  was  followed,  sooner  or  later,  by  alveolar  abscess.  The  conclu- 
sion, therefore,  that  such  teeth  could  not  remain  in  the  mouth  with 
impunity,  was  a  very  natural  one.  But  more  recent  experiments  have 
shown  that  it  is  not  a  necessary  consequence. 

Drs.  Maynard  and  Baker  were  the  first  to  show  that  most  of  the 
morbid  phenomena  resulting  from  the  presence  of  a  tooth  in  the  mouth 
after  the  destruction  of  the  pulp  arose  from  the  irritation  produced  by 
the  matter  contained  in  the  pulp  chamber  and  canal  of  the  root.  To 
prevent  their  occurrence,  therefore,  they  proposed  filling  both  chamber 
and  canal  in  such  a  manner  as  completely  to  exclude  everything  else. 
The  accumulation  of  purulent  matter  being  prevented  here,  its  secre- 
tion at  the  extremity  of  the  root  will,  in  a  majority  of  cases,  either 
cease  altogether,  or  go  on  no  faster  than  it  is  reabsorbed,  as  has  been 
shown  by  repeated  experiments.  Thus  it  would  seem  that  the  amount 
of  vitality  which  a  tooth  derives  from  the  investing  membrane  is  suf- 
ficient, ordinarily,  to  prevent  it  from  exerting  any  apparent  morbid 
action  upon  the  surrounding  parts. 


536  DENTAL  SURGERY. 

Although  it  is  desirable  that  the  operation  should  be  performed 
before  any  diseased  action  has  been  set  up  at  the  extremity  of  the  root, 
much  advantage  may  sometimes  be  derived  from  it,  even  after  alveolar 
abscess  has  actually  occurred.  Dr.  Maynax'd  informed  the  author  that 
he  had  succeeded  in  curing  the  disease  by  it,  and  since  that  time  it  has 
become  a  common  practice,  as  great  benefit  results  from  cleansing  and 
filling  the  roots  of  teeth  which  had  given  rise  to  abscess. 

The  application  of  carbolic  acid  or  creasote  to  the  inner  walls  of  the 
sac,  introduced  through  the  canal  in  the  root,  previously  to  filling,  is 
recommended  as  one  of  the  most  certain  means  of  cure.  The  latter 
agent  was  first  recommended  by  Dr.  C.  W.  Ballard,  and  has  been  tried 
by  the  author  with  very  gratifying  results.  It  is  introduced,  on  the  end 
of  a  thread  of  floss  silk,  to  the  sac  at  the  extremity  of  the  root,  through 
the  pulp  cavity  and  canal  of  the  root,  previously  freed  of  all  extraneous 
riiatter.  Another  mode  of  applying  this  agent  to  the  ulcerated  inner 
surface  of  the  sac,  recommended  by  Dr.  F.  H.  Badger,  is  to  throw  it 
into  the  tooth  with  a  syringe,  the  opening  in  the  crown  being  first 
closed  with  a  filling  of  Hill's  stopping,  with  a  perforation  large  enough 
to  admit  the  tube  of  the  instrument.  The  creasote  is  used  in  the  form 
of  a  strong  alcoholic  solution,  say  one  drachm  of  creasote  to  an  ounce 
of  alcohol.  This  being  forcibly  injected  into  the  tooth,  passes  through 
the  sac  at  the  end  of  the  root  and  escapes  through  the  fistulous  opening 
in  the  gum,  where  it  is  caught  on  a  piece  of  soft  sponge  or  a  few  folds 
of  bibulous  paper.  There  are  many  cases  in  which  there  is  simply  a 
slight  morbid  secretion  that  escapes  through  the  tooth  without  any 
discharge  from  the  gums.  The  means  most  efficacious  in  arresting  this 
are  the  same  as  those  recommended  for  the  treatment  of  abscess  of  the 
socket ;  the  creasote  in  this  case,  should  be  introduced  in  the  manner  as 
first  described. 

Dr.  E.  J.  Dunning  stated,  in  a  letter  to  the  author,  in  3850,  that  he 
had  been  for  several  years,  and  was  then,  constantly  in  the  habit  of 
filling  the  roots  of  teeth  after  destroying  their  pulps,  and  also  of 
cleansing  and  filling  the  roots  of  the  teeth  which  had  previously  lost  the 
entire  pulp  and  become  more  or  less  diseased.  He  also  stated  that 
very  few  cases  had  occurred  in  his  practice  where  suppuration  had  su- 
pervened, rendering  the  removal  of  the  tooth  necessary.  He  further- 
more remarked,  that  whenever  the  investing  membrane  and  gums  of 
teeth  treated  in  this  manner  become  thickened  and  swollen,  the  symp- 
toms are  less  severe.  In  proof  of  the  correctness  of  this  opinion,  he 
has  furnished  the  author  with  the  following  details  of  a  case  which 
came  under  his  observation. 

"  A  gentleman  from  the  South  called  immediately  after  his  arrival 
in  this  city,  and  stated  that  during  his  passage  in  the  steamer  he  had 


FILLING   PULP   CHAMBERS   AND   CANALS   OF   TEETH.  537 

been  suffering  intensely  from  pain  in  a  first  superior  molar.  On  exami- 
nation I  found  the  tooth  thoroughly  injected  with  red  blood  and  the 
periosteum  highly  inflamed  and  considerably  thickened,  though  there 
was  no  swelling  of  the  gum.  A  small  cavity  in  the  posterior  approx- 
imal  surface  had  been  filled  with  gold  a  day  or  two  before  sailing.  In 
preparing  the  cavity  for  filling,  arsenic  had  been  used,  to  allay  sensi- 
bility. In  most  cases  I  should  have  advised  the  removal  of  the  tooth, 
for  the  symptoms  were  very  unfavorable  to  any  operation  for  its  pre- 
servation. But  as  the  mouth  was  otherwise  perfectly  healthy,  the  arch 
unbroken,  the  cavity  in  the  tooth  very  small,  and  the  patient  extremely 
anxious  to  preserve  it,  I  determined  to  make  the  trial. 

"  On  examining  the  cavity  carefully,  I  found  that  the  nerve  had 
never  been  exposed  ;  the  arsenic  had  acted  upon  it  through  the  circu- 
lation, and  had  thus  produced  this  severe  inflammation.  Having 
removed  the  layer  of  sound  bone  that  covered  the  nerve,  and  finding 
it  quite  sensitive,  I  made  an  application  of  an  exceedingly  small 
quantity  of  a  mixture  of  arsenic,  morphine,  and  creasote,  and  covered 
it  with  a  metallic  cap  or  arch,  to  prevent  pressure,  followed  by  a  loose 
filling  of  tin  foil.  The  pain  and  much  of  the  soreness  was  immedi- 
ately relieved. 

"  Saw  the  patient  again  on  the  fourth  day ;  found  the  soreness  en- 
tirely gone  ;  had  suffered  no  pain  since  the  application  was  made ;  injec- 
tion remained  the  same.  Found  the  part  of  the  pulp  contained  in  the 
central  cavity  entirely  insensible ;  removed  it ;  finding  the  portion  in 
the  roots  still  sensitive,  made  the  same  application  at  the  entrance  of 
each  canal  and  filled  the  cavity  again  with  tin.  At  this  sitting  ven- 
tured to  file  the  tooth  so  as  to  increase  the  separation  between  it  and 
the  second  molar.  The  filed  surface  showed  the  injection  beautifully, 
the  bone  appearing  a  bright  red,  and  the  line  at  the  junction  with  the 
enamel  very  distinct.  In  three  or  four  days  saw  the  patient  again,  and 
to  my  surprise  and  delight  found  that  the  injection  had  entirely  disap- 
peared, and  the  tooth  almost  as  perfect  in  color  as  any  of  its  neighbors. 
The  nerve  was  then  removed  from  the  roots,  and  its  place  filled  with 
gold,  and  at  a  subsequent  sitting  the  external  cavity  was  filled.  As 
three  months  have  elapsed  since  the  operation-  was  performed,  without 
hearing  from  it,  I  conclude  that  it  is  thus  far  successful." 

The  injectitju  of  the  tooth  from  the  vessels  of  the  pulp  is  of  frequent 
occurrence  in  teeth  to  which  arsenic  is  applied  for  the  purpose  of 
merely  destroying  the  sensibility  of  the  dentine.  At  the  first  meeting 
of  the  American  Society  of  Dental  Surgeons,  Dr.  Hayden  mentioned  a 
case  that  had  a  short  time  before  fallen  under  his  observation,  and 
several  others  were  cited  by  the  author  at  the  same  time.  Since  then 
he  has  met  with  numerous  cases  in  which  this  had  occurred.     It  is 


538  DENTAL  SURGERY. 

doubtless  the  result  of  increased  vascular  action,  excited  in  the  pulp 
by  the  action  of  the  arsenic,  and  it  proves  that  the  blood  globules 
become  disorganized,  and  the  coloring  matter  escapes  into  the  tubuli 
of  the  dentine.  It  occurs,  however,  much  more  frequently  in  the  teeth 
of  young  than  in  those  of  old  persons. 

Treatment  Preparatory  to  Filling  the  Canals  of  Teeth. — The  following 
is  the  method  of  treatment,  preparatory  to  filling  the  root,  pursued  by 
Prof  Gorgas :  "  I  remove  carefully  all  disorganized  pulp  and  decom- 
posed dentine ;  also  all  discolored  dentine,  provided  it  does  not  weaken 
the  walls  of  the  cavity.  Then,  syringing  out  all  loose  particles  of  the 
debris  with  tepid  water,  I  dry  the  canal  to  the  apex  of  the  root  with 
floss  silk,  being  careful  to  leave  an  end  projecting,  so  as  to  permit  its 
easy  removal.  Several  such  pieces  being  used,  a  shorter  piece  is  then 
saturated  with  pure  wood  creasote  or  carbolic  acid,  and  passed  to  the 
■  end  of  the  canal,  leaving  a  slight  projecting  piece  in  the  crown  cavity, 
so  that  it  may  be  seized  with  pliers  when  it  is  to  be  removed. 

"  I  then  introduce  into  the  crown  cavity  a  temporary  filling  of  Hill's 
stopping,  gutta-percha,  or  the  zinc  preparations.  In  twenty-four  hours 
the  canal  is  examined,  and  the  disinfecting  agent  renewed,  if  necessarv. 
When  not  the  slightest  odor  of  purulent  secretion  is  perceptible,  I  then 
apply  on  the  floss  silk  carbolic  acid  mixed  with  a  little  chloroform, 
replace  the  filling,  and  wait  for  several  days. 

"  If  at  the  end  of  this  time  there  is  no  trace  of  diseased  action,  I  fill 
the  canal  with  gold ;  then  wait  a  few  days  until  all  chance  of  irritation 
from  the  pressure  used  in  the  operation  has  passed  away,  and  then 
complete  the  filling.  But  not  unfrequently  it  is  necessary  to  repeat 
this  course  of  treatment  several  times.  In  one  case,  two  months 
were  required  before  the  tooth  was  in  a  condition  to  warrant  me  in 
filling  it. 

"  In  some  cases  I  deem  it  prudent  to  insert  a  filling  of  '  Hill's  stop- 
ping' for  several  months,  especially  when  there  is  the  slightest  doubt 
of  the  arrest  of  the  disease ;  for  the  gold  once  introduced  into  the 
canal,  it  is  exceedingly  tedious  and  difficult  to  remove  it.  Disease  on 
the  outside  of  the  extremity  of  the  root  may  be  controlled  by  creasote, 
carbolic  acid  or  nitrate-  of  silver,  applied  through  the  fistulous  or  an 
artificial  opening  in  the  alveolus.     (See  Alveolar  Abscess.) 

"Chloride  of  zinc  may  be  used  instead  of  creasote,  when  the  smell 
of  the  latter  is  particularly  repulsive  to  the  patient ;  also  a  combination 
of  carbolic  acid  or  creasote  and  iodine,  as  Dr.  Leech's  formula,  which 
is  composed  of  iodine  (crystals),  Z] ;  carbolic  acid  (crystals),  3  j ; 
alcohol,  foij,  applied  on  a  pledget  of  cotton,  or  on  floss  silk,  or  a  satu- 
rated solution  of  iodoform  and  ether ;  or  eucalyptus  combined  with 
iodoform,  as  Dr.  Parmele's  formula,  which  is  composed  of  eucalyptus 


FILLING   PULP  CHAMBERS   AND   CANALS   OF  TEETH. 


539 


oil,  5j;  iodoform,  gr.  x;  water,  Ij;  all  of  which  are  excellent  anti- 
septics. Any  trace  of  the  living  pulp  should  be  treated  with  some 
devitalizing  agent,  which  may  be  introduced  upon  floss  silk  before 
commencing  the  antiseptic  treatment." 

Fig.  354  represents  Iridio-platinum  Nerve  Broaches  for  extracting 
dead  pulps  of  teeth,  and  for  introducing  into  the  pulp  canal  medicinal 

Fig.  354. 


SO 


agents  in  the  treatment  of  diseased  teeth.  They  do  not  corrode  when 
exposed  to  moisture,  acids,  iodine,  etc.,  and  can  be  cleansed  perfectly 
by  heating  to  redness  in  the  flame  of  a  spirit  lamp. 

Fig.  355  represents  a  set  of  Dr.  B.  F.  Arrington's  devitalized  nerve 
extractors  and  canal  pluggers,  of  drawn  and  spring  temper. 


Soft. 


Fig.  355. 

Spring  Tempeb.  Soft. 


Spring  Temper. 


Fig.  356. 


Filling   Pulp    Chambers    and   Canals    of   Teeth. — For   filling   pulp 
canals   very  nice  instruments   may  be   made  from   piano   wire  filed 


540 


DENTAL,  SUEGERY. 


Fig.  357. 


■===1^ 


to  any  desired  size,  and  fitted  into  suitable  handles, 
such  as  are  represented  by  Fig.  357.  This  wire  is 
very  tough  and  elastic.  The  gold  used  for  filling 
pulp  canals  should  be  non-cohesive  and  folded 
into  a  very  light  ribbon,  and  this  cut  into  square 
pieces,  which  should  be  placed  upon  a  piece  of 
folded  chamois  skin  and  carried  to  the  pulp^ canal 
by  means  of  the  nerve-canal  plugger  point.  Piece 
after  piece  of  the  gold  is  carefully  introduced  to 
the  apex  or  upper  extremity  of  the  root  until  the 
entire  canal  is  filled.  The  cavity  in  the  crown  is 
then  filled  in  the  usual  manner. 

Fig.  356  represents  a  set  of  nerve  instruments 
contrived  by  Dr.  Corydon  Palmer,  for  forming  the 
canals  in  the  roots  of  the  teeth. 

Fig.  358  represents  Dr.  Hunter's  set  of  pulp- 


canal  pluggers,  some  of  which  are  of  drawn  and 

others  of  spring  temper. 

After  the  cavity  of  decay  in  the  crown  has  been 

properly  prepared,  by  means  of  the  instruments 

represented  in  Fig.  356,  the  pulp  chamber  can  be 
excavated  and  so  shaped  as  to  assist  in  the  retention  of  the  gold. 
Some  operators  drill  out  these  canals,  and  thus  give  them  the  same 
diameter  from  their  orifice  at  the  pulp  chamber  to  the  apex  of  the 
root,  but  this  is  considered  by  many  to  be  an  unnecessary  as  well  as 
dangerous  operation,  as  the  instrument  may  pass  through  the  side  of 
the  root,  particularly  where  the  root  happens  to  be  curved.  Reaming 
out  and  enlarging  the  orifice  of  the  canal  will  be  sufficient  in  the 
majority  of  cases. 

Others  are  satisfied  with  cleansing  them  perfectly  of  all  debris,  and 


FILLIXG   PULP    CHAMBERS    AND    CANALS    OF   TEETH.        541 


Fig.  359. 


decomposed  dentine.  Whichever  method  is  pursued,  care  is  necessary 
that  the  instrument  is  not  passed  beyond  the  foramen,  which  is  more 
liable  to  occur  in  the  case  of  young  patients,  when  the  teeth  are  not 
fully  developed,  than  afterward  ;  for 
then  there  is  generally  such  a  decided 
contraction  of  the  root  canal  near  the 
apex  as  to  arrest  the  progress  of  the 
instrument. 

Fig.  359  represents  a  set  of  N^erve 
Canal  Reamers,  devised  by  Dr.  E.  E. 
Hopkins,  for  the  enlargement  of  the 
canals  prior  to  the  filling  of  the  same. 

Besides  the  method  of  filling  the 
roots,  described  above,  there  are  several 
others,  one  of  which  consists  in  rolling 
strips  or  folds  of  gold  on  a  fine  broach 

in  such  a  manner  as  to  form  cone-shaped  cylinders,  somewhat 
longer  than  the  canal  is  deep,  of  different  sizes  and  density. 
The  soft  rolled  are  first  introduced  by  means  of  the  pliers,  and 
carried  up  as  near  to  the  apex  of  the  root  as  is  possible,  each 
one  being  condensed  against  the  side  of  the  canal.  Successive 
cylinders  are  introduced  in  this  manner  and  condensed  until 
the  canal  is  filled,  the  last  ones  which  form  the  centre  of  the 
filling  being  dense.  Pure  gold  or  platinum  wire  is  sometimes 
employed  for  filling  these  canals,  so  shaped  as  to  correspond  in 
size  and  taper  with  the  cavity.  These  wires  should  be  coated 
with  gutta-percha  or  oxyphosphate  of  zinc  before  introducing 
them. 

It  sometimes  happens  that  the  canals  in  the  buccal  roots  of 
the  superior  molars  are  so  small  as  to  preclude  the  introduction 
even  of  a  small-sized  bristle.  In  cases  of  this  kind  it  is 
impossible  to  fill  them,  and  fortunately,  from  their  small  size, 
they  cannot  serve  as  reservoirs  for  the  accumulation  of  morbid 
matter.  The  canal  in  the  palatine  root  is  always  much  larger 
than  in  either  of  the  buccal  roots,  and  in  a  majority  of  the  cases 
is  filled  with  comparative  ease.  Although  gold  and  tin  are  the 
only  metals  suitable  for  filling  root  canals,  yet  some  non- 
metallic  substances  have  answered  well  when  employed  for ' 
this  purpose,  such  as  Hill's  stopping  and  the  oxyphosphates. 
For  bleaching  teeth  which  have  become  discolored  from  loss  of 
vitality,  the  reader  is  referred  to  the  chapter  on  "  Necrosis." 

In  the  treatment  of  the  canals  of  devitalized  teeth,  if  there  is 
a  secretion  of  liquid  (protoplasm)  through  the  foramen  into  the 


542  DENTAL   SURGERY. 

pulp  canal,  bibulous  paper  or  absorbent  cotton  may  be  employed 
for  drying  the  canal,  when  chloride  of  zinc,  in  a  deliquesced  form, 
should  be  introduced  on  cotton  wound  about  a  broach,  which  will 
coagulate  the  fluid  emanating  from  the  elements  of  the  tissues  about 
the  apex  of  the  root,  and  the  canal  can  at  once  be  permanently 
filled.  A  putrescent  pulp  remaining  in  the  root  canal  gives  rise  to  the 
formation  of  sulphuretted  and  phosphoretted  hydrogen  gas  from  the  dis- 
integrating tissue,  which,  with  the  particles  of  such  tissue  and  the 
foreign  matter  forced  through  the  foramen,  causes  irritation  of  the 
tissues  surrounding  the  apex  of  the  root.  The  secretion  of  pus  will 
continue  as  long  as  the  putrescent  matter  remains  in  the  canal,  and 
the  mephitic  gas  evolved  from  it  through  the  apicial  foramen.  And 
relief  is  experienced  only  when  the  suppurating  surface  is  destroyed 
and  a  normal  action  brought  about  by  the  removal  of  the  irritating 
•matter  and  the  action  of  an  escharotic,  such  as  carbolic  acid  or  creasote, 
assisted  by  injections  of  warm  water  as  a  cleansing  process. 


CHAPTEE  V. 

EXTRACTION    OF   TEETH. 

THERE  are  few  operations  in  surgery  that  excite  stronger  feelings 
of  dread,  and  to  which  most  persons  submit  with  more  reluctance, 
than  the  extraction  of  a  tooth.  Many  endure  the  tortures  of  tooth- 
ache for  weeks,  and  even  months,  rather  than  undergo  the  operation  ; 
and,  indeed,  when  we  take  into  consideration  the  frequent  accidents 
occurring  in  its  performance  by  awkward  and  unskillful  individuals, 
it  is  not  surprising  that  it  should  be  approached  with  apprehension. 
But  when  performed  by  a  skillful  hand  and  with  a  suitable  instrument, 
the  operation  is  always  safe,  and  in  a  large  majority  of  the  cases  may 
be  effected  with  ease. 

Dr.  Fitch  relates  a  case  which  will  serve  to  illustrate  the  above  re- 
marks. The  subject,  a  resident  of  Botetourt  County,  Va.,  in  having 
the  second  right  superior  molar  extracted  by  a  blacksmith,  had  a  large 
portion  of  the  jaw  and  fiv^e  other  teeth  removed  at  the  same  time. 
"The  roots  of  his  tooth,"  says  Dr.  Fitch,  "  were  greatly  bifurcated 
and  dovetailed  into  the  jaw,  and  would  not  pass  perpendicularly  out, 
though  a  slight  lateral  motion  would  have  moved  them  instantly.  The 
jaw  proved  too  weak  to  support  the  monstrous  pull  upon  it,  and  gave 
way  between  the  second  and  first  molars,  and  with  it  came  both  the 


EXTRACTION    OF    TEETH.  543 

anterior  and  posterior  plates  of  the  antrum.  The  broken  portion  ex- 
tended to  the  spongy  bones  of  the  nose,  and  terminated  at  the  lower 
edge  of  the  socket  of  the  left  front  incisor,  containing  six  sound  teeth, 
namely,  the  first  molar,  the  bicuspids,  cuspid,  and  incisors  of  the  right 
side — six  in  all.  The  soft  parts  were  cut  away  with  a  knife.  A  severe 
hemorrhage  ensued,  but  the  patient  soon  recovered,  though  with  exces- 
sive deformity  of  his  face  and  mouth.'" 

Dr.  Cross,  of  North  Carolina,  related  to  the  author,  in  1838,  a  case 
very  similar  to  the  one  just  quoted.  The  operator  in  this,  as  in  the 
other  instance,  was  a  blacksmith ;  in  attempting  to  extract  one  of  the 
superior  molar  teeth,  he  brought  away  a  piece  of  the  jaw  containing 
five  other  teeth,  together  with  the  floor  of  the  antrum  and  its  posterior 
and  anterior  walls. 

We  have  adverted  to  these  cases  to  show  the  impropriety  and  danger 
of  intrusting  the  operation  to  individuals  possessing  neither  knowledge 
of  its  principles  nor  skill  in  its  performance.  Injuries  occasioned  by 
the  operations  of  such  persons  have  frequently  come  under  the  imme- 
diate observation  of  the  author,  with  whom  it  has  always  been  a  matter 
of  surprise  that  an  operation  to  which  such  universal  repugnance  is 
felt  should  ever  be  confided  to  them. 

The  removal  of  a  wrong  tooth,  or  of  two  or  three  instead  of  one,  are 
such  common  occurrences,  that  it  were  well  if  the  precautions  given 
by  the  illustrious  Ambrose  Pare  were  more  generally  observed.  So 
fearful  was  he  of  injuring  the  adjacent  teeth,  that  he  always  isolated 
the  tooth  to  be  extracted  with  a  file  before  he  attempted  its  removal. 
He  regarded  it  as  of  the  greatest  importance  that  a  person  who  ex- 
tracted teeth  should  be  expert  in  the  use  of  his  "  tooth  mullets ;  for 
unless  he  knows  readily  and  cunningly  how  to  use  them,  he  can  scarcely 
so  carry  himself  but  that  he  will  not  force  out  three  teeth  at  once." 
Although  great  improvements  have  been  made  since  his  time  in  the 
construction  of  extraction  instruments,  yet  even  now  the  accidents  to 
which  he  alludes  are  of  almost  daily  occurrence. 

It  is  surprising  that  an  operation  so  frequently  called  for  should 
receive  so  little  attention  from  medical  practitioners,  by  whom,  though 
not  strictly  belonging  to  their  province,  it  must  frequently  be  per- 
formed. This  neglect  can  only  be  accounted  for  by  the  too  general 
prevalence  of  the  idea  that  little  or  no  surgical  skill  is  necessary  to  its 
performance.  But  every  physician  residing  in  the  country,  or  where 
the  services  of  a  skillful  dentist  cannot  always  be  commanded,  should 
provide  himself  with  the  proper  instruments,  and  make  himself  ac- 
quainted with  the  manner  of  performing  this  operation. 


544  DENTAL,  SURGERY. 

INDICATIONS   FOR   THE    EXTRACTION   OF    TEETH. 

With  regard  to  the  indications  that  determine  the  propriety  of  ex- 
traction, the  author  does  not  deem  it  necessary  to  say  much  in  this 
place,  as  they  are  fully  pointed  out  in  other  parts  of  the  work.  It  may 
be  well,  however,  to  briefly  mention,  in  this  connection  a  few  of  the 
circumstances  which  call  for  the  operation. 

Beginning  with  the  teeth  of  first  dentition,  it  will  be  sufficient  to 
state,  that  when  a  tooth  of  replacement  is  about  to  emerge  from  the 
gums,  or  has  actually  made  its  appearance,  either  before  or  behind  the 
corresponding  milk  tooth,  the  latter  should  at  once  be  removed  ;  and 
when  the  aperture  formed  by  the  loss  of  this  is  so  narrow  as  to  pre- 
vent the  former  from  acquiring  its  proper  position,  it  may  sometimes 
be  necessary  to  extract  an  adjoining  temporary  tooth.  For  more  ex-- 
plicit  directions  upon  this  subject,  the  reader  is  referred  to  the  chapter 
on  second  dentition.  Alveolar  abscess,  necrosis  of  the  walls  of  the 
alveolus,  and  pain  in  a  temporary  tooth,  which  cannot  be  cured  by  any 
of  the  usual  remedies,  may  be  regarded  as  indications  which  call  for 
the  operation. 

The  principal  conditions  which  should  determine  the  extraction  of 
a  permanent  tooth  may  be  enumerated  in  the  following  order :  First, 
when  a  molar,  from  the  loss  of  its  antagonizing  tooth,  or  from  other 
causes,  has  become  partially  displaced,  or  is  a  source  of  constant  irri- 
tation to  the  surrounding  parts. 

Second,  a  constant  discharge  of  fetid  matter  from  the  pulp  cavity, 
through  a  carious  opening  in  the  crown.  There  may,  however,  be 
circumstances  which  would  justify  a  practitioner  in  permitting  or 
even  advising  the  retention  of  such  a  tooth  ;  as,  for  example,  when  the 
discharge  of  fetid  matter  is  not  very  considerable ;  also,  where  the 
tooth  is  situated  in  the  anterior  part  of  the  mouth,  and  cannot  be 
securely  replaced  with  an  artificial  substitute.  The  secretion  of  fetid 
matter  may,  in  some  cases,  by  judicious  treatment  be  arrested,  the 
tooth  preserved  for  many  years  by  plugging;  and  so  the  morbid  in- 
fluence it  would  otherwise  exert  upon  the  surrounding  parts  may  be 
counteracted.  A  front  tooth  should  not  be  sacrificed  unless  called  for 
by  some  very  urgent  necessity;  neither  should  an  upper  incisor  nor 
cuspid  be  permitted  to  remain  in  the  mouth,  if  it  exerts  a  manifestly 
morbid  action  upon  the  surrounding  parts,  for  in  this  case  the  conse- 
quences resulting  from  its  retention  in  the  mouth  may  be  worse  than 
the  loss  of  the  tooth. 

Third,  a  tooth  which  is  the  cause  of  an  incurable  alveolar  abscess, 
should  not  be  permitted  to  remain  ;  but  if  it  be  an  incisor  or  cuspid, 
and  the  discharge  of  matter  through  the  gum  is  small,  occurring  only 


EXTRACTION   OF   TEETH. 


545 


at  long  intervals,  and  especially  if  the  organ  cannot  be  securely  re- 
placed with  an  artificial  substitute,  it  may  be  permitted  to  remain. 
An  incurable  abscess  in  the  socket  of  a  bicuspid  or  molar  should 
always  be  considered  as  a  sufficient  indication  for  the  removal  of  the 
tooth. 

Fourth,  irregularity  in  the  arrangement  of  the  teeth,  arising  from 
disproportion  between  the  size  of  the  teeth  and  the  size  of  the  alveolar 
arch,  usually  requires  for  its  correction  the  extraction  of  some  one 
or  more  teeth.  But  with  regard  to  the  teeth  most  proper  to  be  re- 
moved, the  reader  is  referred  to  the  chapter  on  irregularity,  where  he 
will  find  full  directions  for  the  management  of  such  cases. 

Fifth,  all  dead  teeth  and  roots  of  teeth  which  act  as  irritants,  and 

Fig.  360. 


teeth  which  have  become  so  much  loosened,  from  the  destruction  of  their 
sockets,  as  to  be  a  constant  source  of  disease  to  the  adjacent  parts  ;  or 
teeth  otherwise  diseased,  that  are  a  cause  of  neuralgia  of  the  face,  dis- 
ease of  the  maxillary  sinus,  dyspepsia,  or  any  other  local  or  constitu- 
tional disturbance,  such  teeth  should,  as  a  general  rule,  be  extracted. 

There  are  other  indications  which  call  for  the  extraction  of  teeth, 
but  the  foregoing  are  among  the  most  common ;  they  will  be  found 
sufficient,  in  most  instances,  to  determine  the  propriety  or  impropriety 
of  the  operation.  Cases  are,  however,  continually  presenting  them- 
selves, to  which  no  fixed  rules  would  be  found  applicable,  and  where 
an  experienced  judgment  alone  can  determine  the  practice  proper  to 
be  pursued. 

35 


546  DENTAL   SUEGERY. 

In  conclusion,  it  is  scarcely  necessary  to  say,  that  whenever  a  tooth 
can  be  restored  to  health,  it  should  always  be  done ;  but  tampering 
with  such  as  cannot  be  rendered  healthy  and  useful,  and  which,  by 
remaining  in  the  mouth,  exert  a  deleterious  influence,  not  only  upon 
the  adjacent  parts,  but  also  upon  the  general  health,  cannot  be  too 
strongly  deprecated. 

Fig.  360  represents  the  permanent  teeth  of  the  left  side,  a  study  of 
which  will  enable  the  student  to  form  a  correct  idea  concerning  crowns 
and  roots  of  the  different  classes  of  teeth. 

INSTRUMENTS    EMPLOYED   IN   THE   OPERATION. 

Different  operators  employ  different  instruments.  For  about  fifty 
years,  the  key  of  Garengeot  was  almost  the  only  instrument  used  in 
the  performance  of  the  operation ;  but  this  has,  in  a  great  measure, 
been  superseded  by  forceps,  which,  when  properly  constructed,  are  far 
preferable ;  yet  as  the  key  is  still  used  by  some,  and  by  them  is  con- 
sidered, in  certain  cases,  a  valuable  instrument,  a  brief  description  of 
it  is  here  given. 

Key  Instrument. — "  The  common  tooth-key,"  says  Dr.  Arnot,  "  may 
be  regarded  in  the  light  of  a  wheel  and  axle ;  the  hand  of  the  operator 
acting  on  two  spokes  of  the  wheel  to  move  it,  while  the  tooth  is  fixed 
to  the  axle  by  the  claw,  and  is  drawn  out  as  the  axle  turns.  The 
gum  and  alveolar  process  of  the  jaw  form  the  support  on  which  the 
axle  rolls." 

Different  dentists  have  their  keys  differently  constructed,  but  the 
principle  upon  which  they  all  act  is  precisely  the  same.  Some  prefer 
the  bent  shaft  (Fig.  361),  others  the  straight.  Some  give  a  decided 
preference  to  the  round  fulcrum,  others  to  the  flat ;  and  though  the 
success  of  the  operator  depends  greatly  upon  the  perfection  of  the 
instrument,  yet  he  may  remove  a  tooth  more  expertly  by  means  of  a 
key  with  which  he  is  familiar,  than  one  to  which  he  is  unaccustomed, 
though  its  construction  be  even  better.  Fig.  361  represents  a  key  with 
bent  shaft  and  two  hooks,  one  for  molars  and  the  other  for  bicuspids. 

Fig.  361. 


EXTEACTION   OF   TEETH.  547 

The  author  has  tried  almost  every  variety  of  key  instrument  that 
has  been  used  in  this  country,  and  thinks  the  straight  shank,  with  a 
small  round  fulcrum  slightly  flattened  on  each  side,  decidedly  prefer- 
able to  any  other.  The  objection  raised  by  some  to  the  use  of  such  a 
key,  that  it  is  liable  to  interfere  with  the  front  teeth,  is  without  good 
foundation.  It  can  be  used  with  as  much  safety  as  a  key  of  any  con- 
struction, and  in  most  cases  can  be  as  easily  applied.  The  round  is 
certainly  preferable  to  the  flat  fulcrum,  because  it  is  less  liable  to 
injure  the  gums  and  the  alveolus.  In  size  it  should  be  a  little  larger 
than  a  half-ounce  bullet. 

Every  key  instrument  should  be  supplied  with  several  hooks,  differ- 
ing in  size,  to  suit  the  teeth  upon  which  they  are  to  be  applied.  The 
hook  described  by  Dr.  Maynard*  is  preferable  to  any  which  the  author 
has  seen.  It  very  nearly  resembles  the  eagle's  claw,  except  that  its 
curvature  is  rather  greater.  The  edge  of  the  hook  is  about  the  six- 
teenth of  an  inch  in  width,  and  divided  into  two  points  by  a  shallow 
notch.  A  hook  of  this  description  is  less  liable  to  slip,  and  can  be 
more  readily  applied  to  a  tooth  than  those  ordinarily  used. 

With  regard  to  the  merits  of  the  key  instrument,  or  of  any  other 
instrument  having  the  same  principle  of  action,  as  compared  with  the 
forceps  presently  to  be  described,  the  author  does  not  entertain  a  very 
high  opinion.  The  following  remarks,  quoted  from  the  late  work  of 
M.  Desirabode,  accord  with  the  views  which  he  has  held  and  promul- 
gated for  many  years :  "  One  of  the  most  common  causes  of  fracture 
of  the  alveoli  is  a  badly  performed  operation  in  the  mouth ;  although 
not  a  very  flattering  acknowledgment  for  our  art,  it  is  necessary  to  say 
it.  If  it  be  necessary  to  specify  causes,  we  would  not  hesitate  to  name, 
in  the  first  plaCe,  the  use  of  the  key  of  Garengeot ;  for  we  shall  prove, 
in  treating  of  the  extraction  of  teeth,  that  this  dangerous  implement, 
which  is  only  fit  to  mask  the  unskillfulness  of  the  operator,  is  one  of 
the  most  defective  of  surgical  instruments  ;  and  no  practitioner  of  good 
sense,  being  convinced  of  its  mode  of  action,  would  attempt  to  use  it 
even  to  extract  a  nail  from  a  board,  if  he  did  not  desire  to  break  the 
surrounding  material."  Perhaps  this  condemnation  is  too  sweeping. 
The  principle  of  action  of  the  key  is,  in  fact,  not  unlike  that  of  a  nail 
drawer  or  tack  puller,  and  is  well  adapted  to  a  certain  class  of  cases ; 
namely,  where  one  wall,  either  the  inner  or  outer,  is  decayed  below  the 
alveolus,  while  the  opposite  one  is  still  standing.  The  fulcrum,  with  a 
folded  napkin  or  other  soft  substance  interposed,  is  placed  against  the 
gum  on  the  side  of  the  tooth  most  decayed,  and  the  hook  adjusted  to 
the  neck  of  the  tooth  on  the  opposite  side. 

Manner  of  Using  the  Key  Instrument. — The  directions  required  for 

*  See  Am.  Jour.  Dent.  Sci.,  No.  3,  vol.  iii. 


548  DENTAL   SURGERY. 

the  use  of  the  key  are  few  and  simple,  but  as  cases  frequently  occur  to 
which  uo  general  rules  can  be  applied,  much  will  depend  on  the 
practical  judgment  and  surgical  tact  of  the  operator.  The  first  step  to 
be  taken  in  the  operation  is  to  separate  the  gum  from  the  neck  of  the 
tooth,  down  to  the  alveolus ;  tbis  should  be  done,  not  on  two  sides  only, 
but  round  the  entire  tooth.  For  this  purpose  suitable  lancets  should 
be  provided.  A  straight,  narrow-bladed  kuife,  pointed  at  the  end,  and 
with  one  cutting  edge,  will  be  found  most  convenient  for  performing  the 
operation  on  the  approximal  sides ;  it  may  be  most  effectively  used  by 
passing  the  point  of  the  knife  between  the  neck  of  the  tooth  and  gum, 
down  to  the  alveolus,  with  its  back  downward,  then  cutting  in  the 
direction  of  the  crown.  In  this  way  the  connection  of  the  gum  to  the 
sides  of  the  neck  of  the  tooth  may  be  thoroughly  severed.  The  same 
kind  of  knife,  or  a  common  gum-lancet,  maybe  used  for  separating  the 
gum  from  the  remaining  sides  of  the  tooth.  If  the  gum  is  not  well 
separated,  there  will  be  danger  of  lacerating  it  in  the  removal  of  the 
tooth. 

After  the  tooth  has  been  thus  prepared,  the  key,  with  the  proper 
hook  attached,  should  be  firmly  fixed  upon  it ;  the  fulcrum,  on  the 
inside,  resting  upon  the  edge  of  the  alveolus,  the  extremity  of  the  claw 
on  the  opposite  side,  pressed  down  upon  the  neck.  The  handle  of  the 
instrument  is  then  grasped  with  the  right  hand,  and  the  tooth  raised 
from  its  socket  by  a  firm,  steady  rotation  of  the  wrist.  The  claw 
should  be  pressed  down  with  the  forefinger  or  thumb  of  the  left  hand 
of  the  operator,  until,  by  the  rotation  of  the  instrument,  it  becomes 
securely  fixed  upon  the  tooth.  This  precaution  is  necessary  to  prevent 
it  from  slipping,  an  accident  that  frequently  happens,  and  one  that  is 
always  more  or  less  embarrassing  to  the  dentist. 

If  the  tooth  is  situated  on  the  left  side  of  the  mouth,  the  position  of 
the  operator  should  be  at  the  right  side  of  the  patient ;  but  if  it  be  on 
the  right  side,  he  should  stand  before  him.  For  the  removal  of  a 
tooth  on  the  left  side  of  the  lower  jaw,  or  the  right  side  in  the  upper, 
the  palm  of  the  hand  should  be  beneath  the  handle  of  the  instrument ; 
in  the  extraction  of  one  on  the  right  side  of  the  lower  jaw,  or  on  the 
left  side  in  the  upper,  it  should  be  above.  The  manner  of  grasping 
the  instrument  is  of  more  importance  than  many  suppose.  If  improperly 
held,  the  operator  loses,  to  a  great  extent,  his  control  over  it. 

The  directions  here  given  are,  in  some  respects,  different  from  those 
laid  down  by  other  writers  ;  but  we  are  convinced,  from  much  experi- 
ence, that  they  will  be  found  more  conducive  to  the  convenience  of  the 
operator  and  the  success  of  the  operation  than  those  usually  given  for 
the  use  of  this  instrument. 

There  is  a  diversity  of  opinion  as  to  whether  a  tooth  should  be 


EXTRACTION    OF   TEETH.  549 

removed  inwardly  or  outwardly.  Some  direct  the  fulcrum  of  the 
instrument  to  be  placed  to  the  outside  of  the  mouth,  others  to  the  inside, 
or  on  the  neck  of  the  tooth  itself,  while  others  again  regard  it  as  of  little 
importance  on  which  side  it  is  placed.  Experience  has  taught  us  that 
it  should,  in  the  majority  of  cases,  be  placed  on  the  inside,  especially 
of  the  lower  teeth,  as  they  almost  always  incline  toward  the  interior  of 
the  mouth.  Moreover,  the  edge  of  the  alveolus  is  usually  a  little 
higher  on  the  exterior  edge  of  the  jaw  than  on  the  interior  ;  so  that  the 
first  motion  of  the  instrument,  with  its  fulcrum  on  the  outside,  brings 
the  side  of  the  tooth  against  its  socket ;  thus  nearly  double  the  amount 
of  power  is  required  to  remove  it,  while,  at  the  same  time,  the  pain 
and  the  chances  of  injury  to  the  alveolar  processes  are  very  much 
increased. 

It  is,  however,  frequently  necessary  to  place  the  bolster  of  the  key 
on  the  outside  of  the  tooth  ;  when,  for  instance,  it  is  decayed  in  such  a 
way  as  not  to  afford  a  sufficiently  firm  support  for  the  claw  of  the 
instrument.  But  whenever  it  is  possible  to  remove  a  tooth  inwardly, 
it  should  be  done.  The  alveolar  walls  of  the  upper  teeth  are,  generally, 
thinner  than  those  of  the  lower,  and  do  not  afford  so  strong  a  support 
to  the  fulcrum  of  the  instrument. 

Forceps. — Forceps  were  not  very  generally  or  extensively  employed, 
except  for  the  extraction  of  the  front  teeth,  until  about  the  year  1830  ; 
but  the  improvements  made  in  their  construction  since  that  period  are 
so  great,  that  their  use  has  now,  among  dentists,  superseded  that  of  the 
key. 

The  forceps  formerly  used  were  so  awkwardly  shaped,  and  so  badly 
adapted  to  the  teeth,  that  the  extraction  of  a  large  molar  with  an 
instrument  of  this  description  was  regarded  as  exceedingly  difficult,  and 
even  dangerous;  even  its  practicability  was  doubted  by  many  of  the 
most  experienced  practitioners,  and  hence  the  key  was  almost  the  only 
instrument  resorted  to  for  the  purpose. 

When  we  consider  the  strong  prejudice  that  formerly  existed  against 
the  use  of  forceps,  it  is  not  at  all  wonderful  that  their  employment 
should  have  been  resorted  to  with  caution.  JSTor  is  it  surprising  that  a 
gentleman  of  Mr.  Bell's  intelligence  and  practical  experience  should, 
so  late  as  the  period  of  the  publication  of  the  first  edition  of  this  work, 
1830,  tell  us  that  the  key  is  the  only  instrument  to  be  relied  upon  for 
the  removal  of  teeth  that  are  much  decayed ;  and  that  those  who  have 
heaped  the  most  opprobrium  upon  it  are  glad  to  have  a  concealed 
recourse  to  its  aid. 

This  may  have  been  true  at  the  time  Mr.  Bell  wrote,  but  not  now. 
On  the  contrary,  cases  have  occurred  of  the  extraction  of  teeth  with 
forceps,   upon  which    the    key   had   been   previously   unsuccessfully 


550 


DENTAL  SURGERY. 


employed.  It  is  generally  supposed  that  a  greater  amount  of  force  is 
necessary  to  remove  a  tooth  with  forceps  than  with  the  key,  but  this  is 
a  mistake.  It  does  not  ordinarily  require  as  much.  The  leverage 
gained  by  the  action  of  the  key  is  more  than  counterbalanced  by  the 
greater  amount  of  resistance  encountered  in  the  lateral  direction  of 
the  force  exerted  in  the  removal  of  the  tooth  by  that  instrument.  But 
with  forceps,  the  direction  of  the  power  being  in  the  line  of  the  axis 
of  the  tooth,  an  amount  sufficient  to  break  up  the  connection  with  the 
sockets  and  to  overcome  the  resistance  of  the  walls  of  the  alveolus  is 
all  that  is  required ;  and  any  tooth  can  be  extracted  with  the  forceps 
that  can  be  removed  with  the  key  ;  and  that,  too,  in  the  majority  of 
cases,  with  greater  ease  to  the  operator  and  less  pain  and  danger  to  the 
patient. 

.  In  order  that  forceps  may  be  used  with  ease,  it  is  necessary  they 
should  be  properly  constructed.  Every  operator  should  possess  a 
number  of  pairs  (nine  at  least),  each  with  a  differently  shaped  beak, 
adapted  to  the  necks  of  the  teeth  to  which  they  are  respectively 
designed  to  be  applied. 

For  the  upper  molars  two  (Fig.  362)  are  required,  one  for  each  side, 
curved  just  below  the  joint,  so  that  the  beak  shall  form  an  angle  of 
twenty  or  twenty-five  degrees  with  the  handles,  just  enough  to  clear 
the  lower  teeth.  The  inner  blade  is  grooved  to  fit  the  neck  of  the 
palatine  root ;  the  outer  blade  has  two  grooves,  with  a  point  in  the 
centre  to  fit  the  depressions  just  below  the  bifurcation  of  the  two  buccal 
roots.  Another  valuable  improvement  consists  in  having  one  of  the 
handles  bent  so  as  to  form  a  hook.  This  passes  round  the  operator's 
little  finger,  to  prevent  the  hand  from  slipping. 

Fig.  362. 


Fig.  363  represents  another  form  of  superior  molar  forceps,  right 
and  left,  with  a  greater  curvature  in  the  handles  than  the  Harris 
pattern,  which  many  consider  an  improvement. 


EXTRACTION   OF   TEETH. 


551 


The  handles  should  be  wide,  and  large  enough  to  prevent  them  from 
springing  under  the  grasp  of  the  hand,  to  which  they  should  be  accu- 
rately fitted.  Every  dentist,  therefore,  in  having  forceps  manufactured, 
should  give  special  directions  with  regard  to  their  shape  and  size.  The 
beak  should  be  bent  no  more  than  is  absolutely  necessary  to  prevent 
the  handles  from  coming  in  contact  with  the  teeth  of  the  lower  jaw  ; 
for  in  proportion  to  the  degree  of  curvature  will  the  muscular  power 
of  the  operator  be  disadvantageously  exerted. 


Fig 


Each  blade  of  the  beak  of  the  lower  molar  forceps  has  two  grooves, 
with  a  point  in  the  centre,  so  situated  that  in  grasping  the  tooth  it 
comes  between  the  two  roots  just  at  the  bifurcation.  An  improvement 
made  by  the  author  in  1833  consists  in  having  the  handles  of  the  in- 
strument so  bent  that  it  may  be  as  readily  applied  to  one  side  of  the 
mouth  as  the  other,  while  the  operator  occupies  a  position  to  the  right 
and  a  little  behind  the  patient.  By  this  improvement,  the  necessity 
for  two  pairs  is  superseded ;  it,  moreover,  enables  him  to  control  the 
head  of  the  patient  with  his  left  arm  and  the  lower  jaw  with  his  left 
hand,  rendering  the  aid  of  an  assistant  wholly  unnecessary. 

The  shape  of  the  instrument,  as  improved  by  the  author,  is  shown 
in  Fig.  364.     It  is  now  used  by  many  hundreds  of  operators,  who 

Fig.  364. 


552 


DENTAL  SUEGERY. 


prefer  it  to  any  other  instrument  they  have  ever  employed.  When 
applied  to  a  tooth,  the  handles  turn  toward  the  operator,  at  an  angle 
of  about  twenty-five  or  thirty  degrees.  Without  this  curvature  in  the 
handles,  the  arm  of  the  operator  would  often  be  thrown  so  far  from 
his  body  as  to  prevent  the  proper  control  over  the  instrument.  It  is 
also  important  that  the  handles  should  be  wide  and  accurately  fitted 
to  the  hand.  The  inferior  dentes  sapientise  can  also,  in  the  majority 
of  cases,  be  removed  with  this  form  of  forceps. 

Fig.   365  represents  Wolverton's  inferior  molar  forceps  for  either 
side,  with  longer  points  in  the  centre  of  each  blade  of  the  beak,  which 

Fig.  36o. 


answer  a  good  purpose  where  the  roots  slightly  diverge  and  admit  the 
points  within  the  bifurcation. 

Fig.  366  represents  inferior  molar  forceps  for  the  right  and  left  sides 
of  the  mouth,  which  some  prefer  to  the  single  forceps,  on  account  of  the 
position  of  the  hand  grasping  the  instrument 


Fig.  366. 


EXTRACTION   OF   TEETH. 


553 


Fig.  367  represents  a  lower  molar  forceps  with  plain  beaks,  for  use 
on  either  side;  intended  more  especially,  however,  for  the  inferior  third 
molars. 

For  the  extraction  of  the  upper  incisors  and  cuspids,  one  pair  only 

Fig.  367. 


may  be  used,  although  an  instrument  with  the  inner  concave  beak 
somewhat  narrower  than  the  outer  conforms  more  nearly  to  the  shape 
of  the  necks  of  the  superior  cuspids,  and  is  preferred  by  many  for  the 
removal  of  these  teeth.  (Fig.  868.)  These  should  be  straight,  with 
grooved  or  crescent-shaped  jaws,  accurately  fitted  to  the  necks  of  the 
teeth.  The  beaks  should  also  be  thin,  so  that  they  may  be  easily  intro- 
duced under  the  gum,  up  to  the  edge  of  the  alveolus.  And,  like  the 
superior  and  inferior  molar  forceps,  the  handles  should  be  large  enough 
to  prevent  them  from  springing  in  the  hand  of  the  opei-ator,  with  a 
hook  formed  at  the  end  of  one  of  them. 

Fig.  368. 


«  Owing  to  the  difference  in  size  between  the  superior  central  and 
lateral  incisors,  forceps  with  beaks  much  narrower  than  those  of  the 
common  form  of  superior  incisor  forceps,  are  frequently  required  for 
the  extraction  of  the  latter  teeth.  Fig.  369  represents  an  upper  lateral 
incisor  forceps  with  narrow  beaks. 

Fig.  369. 


554  DENTAL  SURGERY. 

Fig.  370  represents  another  form  of  superior  cuspid  and  bicuspid 
forceps,  in  which  the  beaks  curve  more  than  those  of  the  incisor  forceps. 


Fig 


For  the  extraction  of  the  lower  incisors,  a  pair  of  very  narrow- 
beaked  forceps  are  necessary,  to  prevent  interfering  with  the  teeth  ad- 
joining the  one  to  be  removed.  The  beak  below  the  joint  of  the 
instrument  should  be  bent  downward  at  an  angle  of  about  twenty-five 
degrees  with  the  handles.  (Fig.  371.)  This  is  also  a  very  valuable 
instrument  for  the  extraction  of  the  roots  of  teeth. 

Fig.  371. 


An  instrument  similarly  shaped,  but  with  the  beak  much  longer, 
makes  one  of  the  most  universally  applicable  instruments  that  can  be 
devised.  (Fig.  372.)  The  beak  should  be  made  strong,  but  very 
narrow. 


Fig.  373  represents  an  inferior  incisor  hawk-bill  forceps,  which  is  a 
very  convenient  instrument  for  the  removal  of  these  teeth.  It  is  also 
used  for  the  removal  of  the  lower  cuspids. 

Forceps  for  the  extraction  of  bicuspids  should  have  their  jaws  so 
bent  as  to  be  easily  adapted  to  these  teeth  ;  they  should  be  narrow, 
and  have  a  deeper  groove  on  the  inside  than  those  for  the  upper 


EXTRACTION   OF   TEETH. 
Fig.  373. 


555 


incisors  and  cuspids  ;  like  them,  they  should  be  thin,  yet  strong  enough 
to  sustain  the  pressure  which  it  may  be  necessary  to  apply.  One 
pair  will  answer  for  the  right  and  left  bicuspids  of  the  upper  jaw. 
(Fig.  374.) 

For  the  removal  of  the  cuspids  and  bicuspids  of  the  lower  jaw,  the 
hawk's-bill  forceps  (Fig.  373),  with  crescent-shaped  beaks,  is  often 
employed ;  but  the  instruments  represented  in  Figs.  376  and  385  are, 
we  think,  better  suited  to  the  extraction  of  these  teeth,  and  can  be 
more  conveniently  applied.  No  separate  instrument,  therefore,  is  re- 
quired for  the  removal  of  the  inferior  cuspids. 

Fig.  374. 


The  dentes  sapientise  can,  in  many  cases,  be  extracted  with  the  uni- 
versal bicuspid  forceps,  as  shown  in  Fig.  375,  which  is  half  curved, 


Fig.  875. 


with  two  concave  beaks.  But  there  is  another  kind  of  forceps  which 
may  be  more  conveniently  employed  for  the  removal  of  the  upper 
wisdom  teeth.     The  beak  of  these  is  bent  above  the  joint,  forming 


556 


DENTAL   SURGERY. 

Fig.  376. 


Fig.  377. 


nearly  two  right  angles,  as  shown  in  Fig.  377.  These  forceps,  were, 
we  believe,  invented  by  Dr.  Edward  P.  Church,  about  the  year  1830, 
and  in  those  cases  where  the  superior  dentes  sapientise  are  considerably 
shorter  than  the  second  molars,  they  can  be  successfully  and  advan- 
tageously employed  ;  and,  indeed,  in  many  cases,  they  cannot  be  reached 
with  any  of  the  above  described  extracting  instruments.  The  handles 
of  these,  as  of  all  other  forceps,  should  be  no  longer  than  is  absolutely 
necessary  for  the  accommodation  of  the  hand  of  the  operator. 

For  the  removal  of  the  inferior  dentes  sapientise,  the  forceps  repre- 
sented in  Fig.  364,  Harris's  pattern,  or  the  ones  represented  in  Figs. 
366  and  367  may  be  employed.  Fig.  378  represents  Physick's  dentes 
sapientiee  for  either  side,  which  is  used  as  an  elevating  forceps. 

Fig.  378. 


For  the  removal  of  the  roots  of  the  teeth,  the  inferior  incisor  forceps, 
represented  in  Figs.  371  and  372,  are  very  useful ;  also  the  forms  repre- 
sented in  Figs  379  and  380. 

Figs.  381,  382,  383,  384  and  385  represent  Parmley's  patterns  of 
alveola  forceps  for  cutting  through  the  alveolar  process  to  the  roots  of 
the  teeth. 

The  form  of  forceps  represented  by  Fig.  385  is  very  useful  for  the 


EXTRACTION   OF   TEETH. 


557 


extraction  of  inferior  cuspids  and  bicuspids,  both  right  and  left ;  also 
for  the  extraction  of  roots  of  inferior  teeth. 


Fig.  379. 


Fig.  380. 


Fig.  381. 


Fig.  382. 


558 


DENTAL  SURGERY. 
Fig.  385. 


Figs.  386  and  387  represent  Stellvvagen's  superior  and  inferior  forceps 
for  separating  the  diverging  roots  of  molar  teeth,  and  which  may  also 
be  used  as  elevating  forceps. 

There  is  scarcely  any  instrument  used  in  dentistry  that  has  called 
forth  more  ingenuity  in  devising  various  shapes  than  forceps.    Almost 

Fig.  386.     (Superior.) 


every  practitioner  has  some  peculiar  pattern  of  his  own,  which  will 
accomplish  what  no  other  can.  Doubtless  many  of  these  instruments 
are  very  excellent  ;  but  it  often  happens  that  an  inventor  learns,  by 
dint  of  practice,  to  do  with  some  pet  forceps  of  his  own  contrivance 
what  might  as  easily  have  been  done  w'ith  a  simpler  one  already  in  use. 
We  would  not,  however,  be  understood  as  saying  that  patterns  in 
present  use  admit^f  no  improvement.  What  we  do  assert  is,  that 
skill  in  the  use  of  a  few  instruments  is  preferable  to  crowding  one's 
case  with  an  unnecessary  number. 


EXTRACTION   OF   TEETH. 


559 


MANNER   OF   USING   THE   FORCEPS. 


Fig.  388. 


In  describing  the 
manner  of  using  these 
instruments,  ^\e  shall 
commence  with  the  ex- 
traction of  the  incisors 
of  the  upper  jaw.  These 
are  generally  more  easi- 
ly removed  than  any  of 
the  other  teeth. 

The  use  of  the  gum 
lancet  should  generally 
precede  the  application 
of  either  the  forceps  or 
the  key.  Many  dentists 
object  to  the  operation 
as  unnecessarily  inflict- 
ing double  pain.  Some 
have  their  forceps  made  with  thin,  sharp  blades,  so  as  to 
sever  the  gum  on  two  sides  in  the  act  of  pressing  up  the 
instrument.  This  practice  may  be  admissible,  perhaps 
necessary,  in  certain  exceptional  cases,  as  with  children,  or 
nervous  persons,  whom  the  act  of  lancing  might  deter  from 
permitting  the  operation  to  be  completed.  But  we  are 
fully  satisfied  that,  as  a  rule,  it  is  very  objectionable,  either 
in  the  use  of  the  key  or  of  forceps.  Owing  to  the  great 
improvement  in  the  form  of  the  edges  of  the  beaks  of  the 
forceps  now  manufactured,  the  use  of  the  gum  lancet  is 
scarcely  necessary,  except  in  the  case  of  teeth  that  stand 
alone,  where  lancing  of  the  gum  may  prevent  the  laceration 
or  tearing  of  the  soft  tissues,  and  also  in  the  case  of  the 
wisdom  teeth  and  roots  of  teeth  imbedded  in  the  gum. 

Figs.  388  and  389  represent  several  forms  of  gum  lancets. 

Fig.  389  represents  a  convenient  two-blade  gum  lancet, 
with  stop. 

After  separating  the  gum,  when  necessary,  from  the  neck 
of  the  tooth,  it  should  be  grasped  with  a  pair  of  straight 
forceps  (Fig.  368  or  Fig.  370,  or,  in  case  the  tooth  is  a 
lateral  incisor,  with  a  narrow  crown.  Fig.  369),  and  pressed 
several  times,  in  quick  succession,  outward  and  inward, 
giving  it  at  the  same  time  a  slight  rotary  motion,  which 
should  be  continued  until  it  begins  to  give  way ;  then,  by 
a  slight. down  ward  pull,  it  is  easily  removed.     If  the  tooth 


560 


DENTAL   SURGERY. 


is  much  decayed,  it  should  be  grasped  as  high  up  under  the  gum  as 
possible,  and  no  more  pressure  applied  to  the  handles  of  the  instru- 
ment than  may  be  necessary  to  prevent  it  from  slipping.  Teeth  are 
often  unnecessarily  broken  by  not  attending  to  this  precaution. 

The  same  directions  will,  in  most  cases,  be  found  applicable  for  the 
removal  of  a  lower  incisor.  But  the  arrangement  of  these  teeth  is 
sometimes  such  as  to  render  their  extraction  rather  more  difficult.  The 
forceps  best  calculated  for  their  removal  are  represented  in  Figs.  371 
and  373. 

For  the  extraction  of  a  cuspid,  more  force  is  usually  required  than 
for  the  removal  of  an  incisor,  because  of  the  greater  size  and  length 
of  its  root.  The  straight  forceps  (see  Fig.  368  or  Fig.  370)  should 
be  employed  for  the  removal  of  the  superior,  and  the  curved-beaked 
forceps  (Figs.  371,  376  and  385)  for  the  inferior  cuspids.  In  the  ex- 
traction of  these  teeth,  less  rotary  motion  should  be  given  to  the  hand 


Fig.  389. 


than  in  the  removal  of  the  incisors;  in  every  other  respect  the  opera- 
tion is  performed  in  the  same  manner.  The  inferior  cuspids  usually 
have  longer  roots,  and  are  more  difl&cult  to  remove  than  the  superior. 
Very  little  rotary  motion  can  be  given  to  a  bicuspid,  especially  an 
upper  one,  in  its  extraction.  After  it  has  been  pressed  outward  and 
inward  several  times,  or  until  it  begins  to  give  way,  it  should  be 
removed  by  pulling  in  the  direct  line  of  its  axis.  For  the  extraction 
of  the  upper,  the  forceps  represented  in  Fig.  368  and  Fig.  370,  and 
for  the  lower,  those  represented  in  Fig.  376  and  Fig.  385,  are  the 
proper  instruments  to  be  employed,  unless  the  crown  has  become  so 
much  weakened  by  decay  that  it  will  not  bear  the  requisite  amount  of 
pressure.  In  this  case  the  gum  on  each  side  should  be  separated  from 
the  alveolus  about  an  eighth  or  three-sixteenths  of  an  inch,  and  slitted 
so  as  to  permit  the  application  of  the  narrow-beaked  forceps.  Fig.  371. 
With  these,  the  alveolar  wall  on  each  side  may  be  easily  cut  through, 


EXTRACTION   OF   TEETH.  561 

and  a  sufficiently  firm  hold  obtained  upon  the  root  of  the  tooth  for  its 
removal.  The  forceps  represented  in  Fig.  395  and  Fig.  396  will  be 
found  better  adapted  for  the  removal  of  the  molars,  Avhen  in  a  similar 
condition,  than  any  other  instrument. 

The  upper  molars,  having  three  roots,  generally  require  a  greater 
amount  of  force  for  their  removal  than  any  of  the  other  teeth.  They 
should  be  grasped  as  high  up  as  possible,  with  one  of  the  forceps  repre- 
sented in  Fig.  362  or  363,  and  then  pressed  outward  and  inward,  until 
the  tooth  is  well  loosened,  when  it  may  be  pulled  from  the  socket.  If 
the  forceps  used  for  the  extraction  of  the  upper  molars  are  of  the  right 
description  and  properly  applied,  they  will  be  found  the  safest  and 
most  efficient  instruments  that  can  be  employed  for  their  removal. 

The  superior  dentes  sapientise  are  usually  less  firmly  articulated  to 
the  jaw  than  are  the  first  and  second  molars ;  they  are  therefore  more 
easily  removed.  When  their  crowns  are  sufficiently  long  to  admit  of 
being  grasped  with  the  bicuspid  forceps  (Fig.  375),  they  may  be  re- 
moved with  this  instrument;  but  when  this  cannot  be  applied  without 
interfering  with  the  anterior  teeth,  the  forceps  represented  in  Fig.  377 
may  be  substituted. 

The  inferior  molars,  although  they  have  but  two  roots,  are  often 
very  firmly  articulated,  and  require  considerable  force  for  their  re- 
moval ;  and  it  sometimes  happens  that,  when  the  approximal  side  of 
one  has  been  destroyed  by  caries,  the  adjoining  tooth  has  impinged 
upon  it  in  such  a  manner  as  to  constitute  a  formidable  obstacle  to  its 
extraction.  Two  teeth  are  often  removed  in  attempting  to  extract  one 
thus  situated,  unless  the  precaution  is  taken  of  filing  ofi"  the  side  of  the 
encroaching  tooth.  This  should  never  be  omitted  in  the  extraction  of  a 
lower  molar  or  bicuspid  locked  in  the  manner  just  described.  It 
sometimes,  though  less  frequently,  happens  that  the  upper  teeth  im- 
pinge upon  each  other  in  the  same  manner ;  in  this  case,  also,  the 
adjoining  tooth  should  be  filed  sufficiently  to  liberate  the  one  that  is  to 
be  extracted  before  attempting  its  removal.  In  applying  forceps  to  an 
inferior  molar,  the  points  on  the  beak  of  the  instrument  should  be 
forced  down  between  the  roots ;  after  having  obtained  a  firm  hold,  the 
tooth  should  be  forced  outward  and  inward  several  times  in  quick 
succession,  until  its  connection  with  the  jaw  is  partially  broken  up,  and 
then  raised  from  the  socket.  If  the  tooth  has  decayed  down  to  the 
neck,  the  points  of  the  beak  may  include  the  upper  edge  of  the 
alveolus,  through  Avhich  they  will  readily  pass,  on  applying  pressure  to 
the  handles,  and  in  this  manner  a  secure  hold  will  be  obtained  upon 
the  tooth.  The  same  should  also  be  done  in  the  extraction  of  a 
superior  molar  in  this  condition. 

The  dentes  sapientise  in  the  lower  jaw,  when  situated  far  back  under 

36 


562  DENTAL   SURGERY. 

the  coronoid  processes,  are  oftentimes  exceedingly  difficult  to  extract ; 
but  with  forceps  like  those  represented  in  Figs.  364,  367  or  385,  they 
may  always  be  grasped  by  an  expert  operator,  except  in  those  cases 
where  their  crowns  have  been  destroyed  by  caries,  when  the  cowhorn 
forceps  represented  in  Fig.  397  will  generally  prove  useful.  It  occasion- 
ally happens  that  the  roots  of  these  teeth  are  bent  in  such  a  manner  as 
to  constitute  a  considerable  obstacle  to  their  removal.  But  when  this 
is  the  case,  the  roots  are  almost  always  turned  posteriorly  toward  the 
coronoid  processes  ;  so  that  after  starting  the  tooth,  if  the  operator  is 
unable  to  lift  it  perpendicularly  from  the  socket,  he  will  have  reason 
to  suspect  its  retention  to  be  owing  to  an  obstacle  of  this  nature.  To 
overcome  this,  as  he  raises  his  hand,  he  should  push  the  crown  of  the 
tooth  backward,  making  it  describe  the  segment  of  a  circle  ;  for  should 
he  persist  in  his  efforts  to  remove  it  directly  upward,  the  root  will  be 
broken  and  left  in  the  jaw.  Fig.  378  represents  an  elevating  forceps 
useful  in  removing  the  dentes  sapientiae  when  they  are  but  partially 
erupted  or  badly  decayed.  The  points  of  the  beaks  of  this  forceps  are 
inserted  between  the  second  molar  and  partially  erupted  wisdom  tooth, 
the  crown  of  the  second  molar  being  the  fulcrum. 

It  sometimes  happens  that  the  roots  of  the  first  and  second  molars 
of  both  jaws,  and  those  of  the  superior  dentes  sapientite,  are  bent,  or 
else  diverge  or  converge  so  much  as  to  render  their  extraction  exceed- 
ingly difiicult.  The  convergency  of  these  roots  is  often  so  great  that, 
in  their  removal,  the  intervening  wall  of  the  alveolus  is  brought  away  ; 
but  neither  from  this,  nor  from  the  removal  of  a  portion  of  the  exterior 
wall,  will  any  unpleasant  results  follow.  Similar  malformations  are 
occasionally  met  with  in  the  roots  of  the  bicuspids,  the  cuspids,  and 
even  the  incisors. 

Other  obstacles  sometimes  present  themselves  in  the  extraction  of 
teeth,  which  the  judgment  and  tact  of  the  operator  alone  will  enable 
him  to  overcome.  The  nature  and  peculiarity  of  each  case  will  suggest 
the  method  of  procedure  most  proper  to  be  pursued.  The  dentist 
should  never  hesitate  to  embrace  a  portion  of  the  alveolus  between  the 
jaws  of  the  forceps,  when  necessary  to  enable  him  to  obtain  a  firm  hold 
upon  the  tooth.  The  removal  of  the  upper  edge  of  the  socket  is  never 
productive  of  injury,  as  it  is  always  subsequently  removed,  more  or 
less  rapidly,  by  the  process  of  absorption.  When  the  crown  of  a  tooth 
has  become  so  much  weakened  by  disease  that  it  will  not  bear  the 
pressure  of  the  instrument,  it  may  be  removed  in  this  manner  without 
inflicting  upon  the  patient  half  the  pain  that  would  be  caused  by  the 
attempt  to  spare  the  thin,  perishable  alveolar  walls. 


EXTRACTION   OF   TEETH.  563 

MANNER   OF    EXTRACTING   ROOTS   OF   TEETH. 

The  extraction  of  roots  of  teeth  is  sometimes  attended  with  con- 
siderable difficulty ;  but  generally  they  are  more  easily  removed  than 
the  whole  teeth,  especially  the  roots  of  the  molars  ;  for,  after  the 
destruction  of  their  crowns,  an  effort  is  usually  made  by  the  economy 
to  expel  them  from  the  jaws.  This  is  done  by  the  gradual  absorption 
of  the  alveolus,  together  with  the  filling  up  of  the  socket  by  a  deposition 
of  ossific  matter  at  the  bottom,  whereby  the  articulation  of  the  root 
becomes  weakened,  and  its  removal  rendered  proportionately  easier. 
The  alveolar  cavities  are  often  wholly  obliterated  in  the  course  of  two 
or  three  years  after  the  destruction  of  the  crowns  of  the  teeth,  and  the 
roots  retained  in  the  mouth,  simply  by  their  connection  with  the  gums  ; 
so  that  for  their  removal  little  more  is  necessary  than  to  sever  this  bond 
of  union  with  a  lancet  or  sharp-pointed  knife. 

The  instruments  usually  employed  in  the  extraction  of  roots  of 
teeth  are  the  hook,  punch,  elevator  and  screw,  all  of  which  are 
represented  in  Fig.  390,  and  also  the  root  forceps  shown  in  subsequent 
figures.  Although  every  dentist  has  the  former  made  to  suit  his  own 
peculiar  notions,  the  manner  of  using  them,  and  the  principle  upon 
which  they  act,  are  the  same.  It  will,  therefore,  be  sufficient  to  say 
that  they  should  be  of  a  convenient  size,  made  of  good  steel,  and  so 
tempered  as  neither  to  bend  nor  break. 

The  hook,  No.  7,  Fig.  390  is  chiefly  used  for  the  extraction  of  the 
roots  of  molar  and  bicuspid  teeth  on  the  left  side  of  the  mouth;  the 
punches,  No.s.  3,  4,  5,  6, 10, 11, 12,  Fig.  390,  for  the  removal  of  those  on 
the  right  side ;  the  elevators,  Nos.  2,  8,  9, 13,  Fig.  390,  for  the  extraction 
of  roots  on  either  side,  as  occasion  may  require  ;  and  the  screw  No.  1, 
Fig.  390,  for  the  removal  of  those  of  the  upper  front  teeth. 

Considerable  tact  is  necessary  for  the  skillful  use  of  these  instru- 
ments, and  this  can  only  be  obtained  by  practice.  Great  care  is  requi- 
site in  usiug  the  punch  and  elevator,  to  prevent  them  from  slipping, 
and  injuring  the  mouth  of  the  patient.  Whenever,  therefore,  either 
of  these  ai"e  used,  the  forefinger  of  the  left  hand  of  the  operator  should 
be  wrapped  with  a  napkin  and  placed  on  the  side  of  the  root  opposite 
to  that  against  which  the  instrument  is  applied,  so  as  to  catch  the 
point  in  case  it  should  slip. 

But  for  the  removal  of  the  roots  of  bicuspids  and  molars,  and  often 
for  those  of  the  cuspids  and  incisors,  the  narrow-beaked  forceps,  recom- 
mended for  the  extraction  of  the  lower  incisors  (see  Fig.  371),  may  be 
used  more  effectively  than  any  other  instrument.  When  the  root  is 
decayed  down  to  the  alveolus,  the  gum  should  be  separated  from  it, 
and  so  much  of  it  as  may  be  necessary  to  obtain  a  secure  hold  upon 
the  root  included  between  the  beaks  of  the  forceps ;  for  these,  being 


564 


DENTAL  SURGERY. 


very  narrow,  readily  pass  through  the  alveolus,  and  a  firm  hold  is  at 
once  obtained  upon  the  root ;  then,  after  moving  it  a  few  times,  out- 
ward and  inward,  it  may  easily  be  removed  from  its  socket. 

There  are  some  cases,  however,  in  which  the  punch,  hook  and  ele- 


FiG.  390. 


vator  may  be  advantageously  used.  We  have  also  occasionally  met 
with  cases  where  we  have  succeeded  in  removing  roots  of  teeth  with 
great  ease  by  means  of  an  elevator  shaped  like  the  blade  of  a  knife, 
first  forcing  it  into  the  socket  by  the  side  of  the  root,  and  then  turning 


EXTRACTION   OF   TEETH. 


565 


it  so  as  to  make  the  back  press  against  the  former  and  the  edge  against 
the  latter.  When  this  instrument,  represented  in  Fig.  391,  is  used, 
the  blade  should  not  be  more  than  an  inch  in  length,  and  it  should  be 
straight,  short  at  the  point,  and  have  a  very  thick  back,  that  it  may 
not  break  in  the  operation.  In  using  the  common  elevator,  it  is  neces- 
sary that  there  should  be  an  adjoining  tooth  or  root  to  act  as  a  fulcrum. 


Fig 


When  this  can  be  employed,  a  root,  or  even  a  whole  tooth,  may  some- 
times be  removed  with  it ;  but,  as  a  general  rule,  forceps  should  be 
preferred  to  any  of  these  instruments. 

For  the  extraction  of  the  roots  of  the  upper  front  teeth,  after  they 
have  become  so  much  funueled  out  by  decay  as  to  render  their  walls 
incapable  of  sustaining  the  pressure  of  forceps,  the  conical  screw  may 
be  employed.  With  this  a  sufficiently  firm  hold  for  the  removal  of  the 
root  can  be  obtained  by  screwing  it  into  the  cavity.  But  before  it  is 
introduced,  the  soft  decomposed  dentine  should  be  removed  from  the 
interior  of  the  root  with  a  triangular-pointed  instrument  like  the  one 
represented  in  Fig.  392. 

Fig.  392. 


Dr.  S.  P.  Hullihen  has  invented  a  most  valuable  and  useful  instru- 
ment for  the  removal  of  the  roots  of  the  superior  incisors  and  cuspids 
when  in  the  condition  just  described.  It  combines  the  advantages  both 
of  the  screw  and  forceps,  as  may  be  seen  by  the  accompanying  cut. 
It  is  thus  described  by  the  author  :  "  Lengthwise,  within  and  between 
the  blades  of  the  beak,  is  a  steel  tube,  one  end  of  which  is  open,  the 
other  solid  and  flat,  and  jointed  in  a  mortice  in  the  male  part  of  the 
joint  of  the  forceps.  When  the  forceps  are  opened,  this  joint  permits 
the  tube  to  fall  backward  and  forward  from  one  blade  of  the  beak  to 
the  other,  without  any  lateral  motion.  Within  this  tube  is  a  spiral 
spring,  which  forces  a  shaft  up  two-thirds  of  the  tube ;  the  other  part 
is  a  well-tapered  or  conical  screw.  .  .  The  shaft  and  tube  are  so  fitted 
together,  and  to  the  beak  of  the  forceps,  that  one-half  of  the  rounded  part 
of  the  shaft  projects  beyond  the  end  of  the  tube  so  that  the  shaft  may 
play  up  and  down  upon  the  spring  about  half  an  inch  and  the  screw 
or  shaft  be  embraced  between  the  blades  of  the  beak  of  the  instrument." 


566 


DENTAL   SURGERY, 


Fig.  393. 


Dr.  Hullihen's  instrument  is  represented  in  Fig.  393. 
"The  forceps,"  says  Dr.  Hullihen,  "  are  used  by  first  embracing  the 
shaft  between  the  blades.*     Then  screwing  it  as  gently  and  deeply  into 

the  root  as  possible,  the 
blades  are  opened  and 
pushed  up  on  the  root, 
which  is  then  seized  and 
extracted.  The  screw 
thus  combined  with  the 
forceps  prevents  the  root 
from  being  crushed.  It 
acts  as  a  powerful  lever  when  a  lateral  motion  is  given  ;  it  is  likewise 
of  advantage  when  a  rotary  motion  is  made;  it  prevents  the  forceps 
from  slipping  or  from  losing  their  action  should  one  side  of  the  root 
■  give  way  in  the  act  of  extracting  it ;  and  is  used  with  equal  advantage 
where  one  side  of  the  root  is  entirely  gone." 

The  opportunities  which  the  author  has  had  of  testing  the  value  of 
this  instrument  have  been  sufficient  to  justify  him  in  stating  that  its 
merits  are  not  overrated  by  the  inventor.  Every  practitioner  would, 
therefore,  do  well  to  provide  himself  with  one  of  them. 

Fig.  394. 


Fig.  394  represents  Dubs'  screw  forceps :  1.  Conical  screw,  with 
square  ratchet  shaft.  2.  Beaks  of  forceps,  grooved  inside.  3.  Socket, 
with  square  hole  to  receive  shaft.  4.  Spring  trigger,  by  which  the 
screw  can  be  detached  at  pleasui^e  at  any  given  point. 

For  the  extraction  of  the  roots  of  the  upper  molars,  before  they 
have  become  separated  from  each  other  by  decay,  the  forceps  (Fig. 
395),  invented  by  Dr.  Maynard,  will  be  found  highly  valuable.  The 
outer  beak  of  each  instrument  is  brought  to  a  sharp  point  for  per- 
forating the  alveolus  between  the  buccal  roots,  and  for  securing  between 

*  The  author  has  a  pair  constructed  so  that  the  blades  of  the  beak  of  the 
forceps  grasp  the  upper  extremity  of  the  screw  iastead  of  the  shaft. 


EXTRACTION   OF   TEETH. 


567 


tliem  a  firm  hold,  while  the  inner  beak  is  intended  to  rest  upon  the 
edge  of  the  alveolus  and  embrace  the  palatine  root.  By  this  means 
a  sufficiently  firm  hold  is  secured  to  enable  the*  operator  to  remove  the 
roots  of  an  upper  molar  without  difficulty.     Two  pairs,  as  represented 


Fig.  395. 


in  the  engraving,  one  for  the  right  and  one  for  the  left  side,  are 
required. 

Fig.  396  represents  a  form  of  forceps  recently  introduced,  which  is 
also  used  for  the  extraction  of  the  roots  of  the  superior  molars  before 
they  have  become  separated  by  decay  ;  a  right  and  left  are  required. 

Fig.  396. 


Fig.  397  represents  a  lower  molar  cowhorn  forceps  for  either  side. 

Fig.  397. 


568 


DENTAL  SURGERY. 


Figs.  398  and  399  represent  lower  molar  cowhorn  forceps  for  the  right 
and  left  side. 

Fig.  398  {Right  Side). 


The  advantage  to  be  derived  from  forceps  of  this  description  must 
be  apparent  to  every  dentist. 

Fig.  400  represents  Tomes'  universal  root  forceps,  which  is  a  very- 
useful  form  for  the  extraction  of  fragments  and  small  roots  of  teeth. 


Fig.  400. 


Fig.  401  represents  Arrington's  bayonet-shape,  slender  beak  forceps 

Fig.  401. 

\ 


EXTEACTION   OP   TEETH. 


569 


for  the  extraction  of  difficult  roots  in  upper  jaw  and  roots  of  front 
teeth  in  the  lower  jaw. 

Figs.  402  and  403  represent  front  and  back  alveolar  nipping  forceps, 
for  cutting  away  processes  after  extraction,  and  which  may  also  be  used 
for  removing  roots  of  teeth. 

Fig.  402. 


Fig.  404  represents  Tees'  sub-alveolar  thin-pointed  forceps,  which 
are  designed  to  slip  within  the  alveolar  process  and  into  the  tooth- 
socket  to  remove  teeth  the  crown  of  which  are  entirely  decayed  or 

broken  off. 

Fig.  404. 


570 


DENTAL   SURGERY. 


EXTRACTION   OF   THE   TEMPORARY   TEETH. 

The  temporary  teeth  should  be  extracted  in  the  same  manner  as  the 
permanent,  and  with  the  same  instruments.  If  the  power  be  properly 
directed,  very  little  force  is  required  for  their  removal ;  because  the 
roots  of  these  teeth  have  generally  suffered  more  or  less  loss  of  sub- 
stance before  the  operation  is  called  for  ;  and  when  they  remain,  the 
alveolar  processes,  at  this  early  age,  are  so  soft  and  yielding  as  to  offer 
little  resistance  to  the  tooth. 

The  operator  should  be  careful  not  to  injure  the  pulps  of  the  perma- 
nent teeth,  or  the  jaw  bone.  Serious  accidents  sometimes  occur  from 
an  improper  or  awkward  removal  of  these  teeth.  But  as  has  been 
before  remarked,  their  extraction  is  seldom  required.  It  should  only 
be  resorted  to  for  the  relief  of  toothache,  the  cure  of  alveolar  abscess,  to 
prevent  irregularity  in  the  permanent  teeth,  or  in  case  of  necrosis  of 
the  socket.  And  even  in  such  cases  it  is  necessary  to  exercise  much 
judgment  in  deciding  how  far  pain  and  inconvenience  should  be 
endured  rather  than  extract  the  offending  tooth  ;  or  how  far  the  chance 
of  injury  to  the  permanent  teeth  demands  the  removal  of  the  diseased 
milk  teeth.  Their  premature  extraction  is  so  often  followed  by  a 
crowded  state  of  the  permanent  teeth,  that  their  indiscriminate  removal, 
for  trifling  causes,  cannot  be  too  stz'ongly  condemned. 

Fig.  405  represents  forceps,  curved  and  straight,  for  the  extraction 
of  children's  teeth. 

Fig.  405. 


Fig.  406  represents  forceps  for  the  extraction  of  children's  teeth,  and 
which  will  also  answer  as  universal  root  forceps. 


Fig.  406. 


EXTRACTION   OF   TEETH.  571 

HEMORRHAGE   AFTER   EXTRACTIOlSr. 

It  rarely  happens  that  excessive  hemorrhage  follows  the  extraction 
of  a  tooth.  Indeed,  it  is  oftener  more  desirable  to  promote  bleeding 
by  rinsing  the  mouth  with  warm  water  than  to  attempt  its  suppression, 
especially  after  the  extraction  of  teeth  affected  with  periodontitis,  as 
such  hemorrhage  relieves  the  congestion  of  the  parts,  and  hastens  re- 
covery. Nevertheless,  cases  do  sometimes  occur  in  which  it  becomes 
excessive  and  alarming.  It  has  been  known,  in  some  instances,  to 
terminate  fatally ;  this,  however,  does  not  appear  to  be  dependent  upon 
the  manner  in  which  the  operation  is  performed,  but  rather  upon  a 
hemorrhagic  diathesis  of  body,  attributable  to  a  deficiency  in  the 
coagulating  property  of  the  blood,  a  defibrinating  condition,  or  heredi- 
tary predisposition.  Hence,  whenever  a  tendency  to  it  exhibits  itself 
in  one  member  of  a  family,  it  is  usually  found  to  exist  in  all. 

There  are  two  forms  of  hemorrhage — the  "  primary,"  which  imme- 
diately follows  the  extraction  of  a  tooth,  and  the  "secondary,"  which 
occurs  after  the  arrest  of  the  primary.  A  patient  may  have  a  tooth 
extracted  during  the  day  and  no  unusual  hemorrhage  result,  which  is 
the  common  experience  ;  but  during  the  night  or  the  next  day,  or  even 
later,  a  serious  flow  of  blood  may  ensue,  which  is  secondary  hemor- 
rhage, and  much  more  difiicult  to  arrest  than  the  primary  form.  Of 
the  many  cases  which  have  fallen  under  our  own  observation,  we  shall 
mention  only  the  following : — 

In  the  fall  of  1834,  Miss  I.,  fifteen  years  of  age,  had  the  second 
molar  on  the  left  side  of  the  upper  jaw  removed.  The  hemorrhage 
immediately  after  the  operation  was  not  greater  than  usually  occurs, 
and  in  the  course  of  half  or  three-quarters  of  an  hour  it  ceased  alto- 
gether. But  at  about  twelve  o'clock  on  the  following  night  it  com- 
menced again,  the  blood  flowing  so  profusely  as  to  excite  considerable 
alarm.  A  messenger  was  immediately  sent  to  ask  our  advice,  and  we 
directed  that  the  alveolar  cavities  should  be  filled  with  pledgets  of 
lint,  saturated  with  tincture  of  nutgalls.  Two  days  after,  at  about 
six  o'clock  in  the  morning,  we  were  hastily  sent  for  by  the  young  lady's 
mother,  and  when  we  arrived  at  her  residence,  we  were  informed  that 
the  bleeding  had  then  been  going  on  for  about  four  hours.  During  this 
time  more  than  two  quarts  of  blood  had  been  discharged.  The  blood 
was  still  oozing  very  fast.  After  we  had  removed  the  coagulum,  we 
filled  the  socket  with  pieces  of  sponge,  saturated,  as  the  lint  had  been, 
with  tincture  of  nutgalls.  When  firmly  pressed  in,  and  secured  by  a 
compress,  the  hemorrhage  ceased.  These  were  permitted  to  remain 
until  they  were  expelled  by  the  suppurative  and  granulating  processes. 
We  afterward  had  occasion  to  extract  one  tooth  for  a  sister,  and  two 
for  the  mother  of  the  young  lady,  and  a  hemorrhage,  similar  to  that 


572  DENTAL  SURGERY. 

just  described  occurred  in  each  case.  Where  the  tendency  to  hemor- 
rhage exists,  due  care  should  be  exercised,  immediately  after  the  ex- 
traction of  teeth,  to  guard  against  its  occurrence  by  the  application  of 
a  reliable  styptic.  Some  of  the  more  simple  local  remedies  for  its 
arrest  are  spider-web  as  a  mechanical  obstructor ;  also  compressed 
sponge  saturated  with  sandarach  varnish,  or  coated  with  soft  wax ;  the 
return  of  single-root  teeth,  coated  with  wax,  to  the  cavity ;  the  lint  of 
black  silk,  owing  to  the  efficacy  of  the  coloring  matter  ;  the  scrapings 
of  leather,  on  account  of  the  tannin  used  in  preparing  it ;  lint  of  old 
linen,  saturated  with  phenol  sodique,  all  of  which  may  be  packed  into 
a  bleeding  cavity,  after  freeing  it  from  blood,  and  kept  in  place,  if 
necessary,  by  a  compress ;  also  the  adaptation  of  a  rubber  plate  accu- 
rately to  the  part,  or  of  modeling  composition,  as  compresses  for  the 
retention  of  the  styptic ;  also  alum  ;  also  matico  leaf,  prepared  by 
immersing  a  piece  in  water  for  a  few  minutes  and  rolling  it  into  pellets, 
or  into  a  cone,  with  the  under  surface  of  the  leaf  outward,  and  packing 
these  into  the  cavity,  after  which  a  compress  is  applied,  and  also  a 
bandage  round  the  head  and  under  the  chin,  to  keep  the  mouth  at  rest. 
The  more  powerful  styptics  for  local  application  consist  of  tannic  acid, 
gallic  acid,  nitrate  of  silver,  tincture  perchloride  of  iron,  solution  of 
persulphate  of  iron,  powdered  subsulphate  of  iron.  Tannin  is  an  ex- 
cellent styptic,  and  answers  well  in  connection  with  the  compress  of 
lint  or  cotton,  in  most  cases ;  also  gallic  acid  ;  and  their  clots  are  not 
soluble  in  the  blood.  The  tincture  perchloride  of  iron  and  the  solu- 
tion persulphate  of  iron,  although  powerful  styptics,  are  not  reliable, 
on  account  of  the  danger  of  sloughing  and  the  occurrence  of  secondary 
hemorrhage.  The  same  is  the  case  with  the  nitrate  of  silver,  the  use 
of  which,  although  it  may  prove  successful  in  some  cases,  is  attended 
with  destruction  of  tissue,  and  its  clot  is  soluble  in  the  blood.  The 
powdered  subsulphate  of  iron  (Monsell's)  applied  to  the  bleeding  cavity 
on  pledgets  of  cotton  saturated  with  sandarach  varnish,  with  a  com- 
press so  adjusted  as  to  act  directly  upon  the  mouth  of  the  bleeding 
vessel,  will  generally  prove  effectual  in  arresting  alveolar  hemorrhage. 
The  compression  should  be  moderate,  and  the  packing  be  allowed  to 
remain  until  all  danger  of  a  return  of  the  bleeding  is  past.  In  many 
cases  of  severe  alveolar  hemorrhage,  it  is  better  to  allow  the  packing 
to  come  away  of  itself.  Constitutional  treatment  is  frequently  neces- 
sary in  connection  with  the  local  treatment,  and  such  internal  remedies 
as  acetate  of  lead,  two  grains ;  opium,  one  grain  ;  tincture  of  per- 
chloride of  iron,  n\,xv-xxx ;  gallic  acid,  gr.  v-x ;  tincture  of  erigeron 
canadensis,  gtt.j,  every  minute;  dilute  hydrochloric  acid,  gtt.  xv  in  a 
wineglass  of  water,  every  four  hours,  will  prove  serviceable  in  obstinate 
and  severe  cases.  Veratrum  viride,  in  doses  of  gtt.v  to  water,  E  ss,  will 


EXTRACTION   OF   TEETH.  573 

depress  the  action  of  the  heart,  and,  as  a  consequence,  prove  beneficial. 
Rest,  and  the  horizontal  position,  with  the  head  and  shoulders  raised, 
are  valuable  adjuncts  to  the  treatment.  In  some  cases  it  may  be  found 
necessary  to  have  recourse  to  the  actual  cautery. 

The  following  case  is  quoted  by  Dr.  Fitch,  from  "  Le  Dentiste  Ob- 
servateur,  par  H.  G.  Courtois,"  Paris,  1775  : — 

"  A  person  living  in  Paris  called  on  me  to  extract  a  canine  tooth 
for  him.  On  examining  his  mouth,  I  thought  that  the  man  was 
attacked  with  scurvy  ;  but  this  did  not  seem  sufficient  to  hinder  the 
patient  from  having  his  tooth  extracted  ;  nor  would  he  consent  to  its 
remaining,  on  account  of  the  pain  which  it  gave  him.  After  the  tooth 
was  extracted,  it  did  not  appear  to  me  that  it  bled  more  profusely  than 
is  customary  after  similar  operations.  The  following  night  I  was  called 
upon  to  see  the  patient,  who  had  continued  to  bleed  ever  since  he  left 
me.  I  employed,  for  stopping  this  hemorrhage,  agaric  from  the  oak 
bark,  which  I  commonly  used  with  success.  The  following  day  I  was 
again  sent  for ;  the  bleeding  still  continued.  After  having  disbur- 
dened the  mouth  of  all  the  lint-pledgets,  which  I  used  for  making 
compression  at  the  place  where  the  blood  appeared  to  come  from,  I 
made  the  patient  take  some  mouthfuls  of  water  to  clear  his  mouth  of 
all  the  clots  of  blood  with  which  it  was  filled  ;  I  perceived  then  that 
the  blood  came  no  longer  from  the  place  where  I  had  extracted  the 
tooth,  but  from  the  gums ;  there  was  not  a  single  place  in  the  whole 
mouth  from  which  the  blood  did  not  issue.  I  called  in  the  physician, 
who  ordered  several  bleedings  in  succession,  besides  astringents,  taken 
internally,  and  gargles  of  the  same  nature ;  but  all  these  attempts  to 
improve  the  coagulability  of  the  blood  were  made  to  no  purpose.  It 
was  not  possible  to  stop  the  hemorrhage.  The  patient  died  the  ninth 
or  tenth  day  after  the  extraction  of  the  tooth." 

The  late  Professor  Gross  was  the  first  to  call  attention  to  a  form  of 
neuralgia  occurring  after  the  extraction  of  teeth,  and  depending  upon 
thickening  and  induration  of  the  alveolar  margin,  by  which  the  re- 
mains of  the  dental  nerves  after  the  removal  of  teeth  become  com- 
pressed and  irritated.  The  treatment  in  such  cases  consists  in  the 
removal  of  the  margin  of  the  alveolus  compressing  the  nerve  with 
cutting  forceps,  and  thus  freeing  the  irritated  tissue. 


574  DENTAL   SURGERY. 


CHAPTER  VI. 

THE    USE    OF     ANESTHETIC    AGENTS    IN     THE    EXTRACTION    OP 

TEETH. 

OF  the  various  agents  that  have  been  employed  for  the  prevention 
of  pain  during  surgical  operations,  sulphuric  ether  and  chloroform 
have  proven  more  successful  and  been  more  generally  used  than  any 
others.  The  practicability  of  producing  anaesthesia  with  ether  was 
first  demonstrated  by  Dr.  Horace  Wells,  of  Hartford,  Conn.,  in  1846, 
and  soon  afterward  brought  prominently  before  the  medical  and  dental 
professions  by  Dr.  W.  G.  S.  Morton,  of  Boston,  Mass.,  both  practical 
dentists ;  and  with  chloroform,  in  1847,  by  Prof.  J.  Y.  Simpson,  of 
Edinburgh,  Scotland.  The  anaesthetic  effect  is  obtained  by  inhalation 
of  the  vapor,  and  is  supposed  to  be  nothing  more  than  a  transient  state 
of  intoxication,  which  usually  disappears  almost  immediately  after  the 
discontinuance  of  the  administration,  though  in  many  cases  it  has 
proved  fatal.  For  this  reason,  we  do  not  think  that  agents  capable  of 
producing  such  powerful  and  dangerous  effects  as  ether  and  chloroform 
should  be  used  in  so  simple  an  operation  as  the  extraction  of  a  tooth. 
The  first,  however,  is  less  dangerous  than  the  second  ;  but  its  anaesthetic 
effect  is  less  certain  and  prompt,  from  seven  to  ten  minutes  being 
usually  required,  whereas,  with  the  other,  it  is  obtained  in  from  thirty 
seconds  to  two  minutes.  When  ether  is  used,  from  six  to  ten  or  fifteen 
ounces  are  employed  ;  but  with  chloroform  it  is  rarely  necessary  to 
administer  more  than  from  thirty  to  one  hundred  and  fifty  drojos. 
What  we  have  said  about  sulphuric  ether  applies  equally  to  chloric 
ether,  a  substance  very  extensively  used,  if  not  first  proposed,  by  the 
late  Prof.  Warren,  of  Boston. 

A  number  of  instruments  have  been  devised  for  the  inhalation  of  the 
vapor  of  these  agents  ;  but  the  simplest  and,  we  think,  the  best  method 
of  administration  is  from  a  hollow  sponge,  a  napkin,  or  a  pocket 
handkerchief. 

It  may  not  always  be  possible  for  any  one,  in  the  administration  of 
either  of  the  foregoing  agents,  even  to  a  person  supposed  to  be  free 
from  any  special  proclivity  to  disease  from  organic  derangement,  to 
pronounce,  d, priori  that  no  badefiect  will  result  from  it;  but  all  agree 
that  it  is  unsafe  to  give  it  to  a  patient  laboring  under  disease  of  the 
heart,  brain,  or  lungs.  The  j)ractitioner,  therefore,  whether  medical 
or  dental,  should  be  well  assured,  before  giving  ether  or  chloroform, 


ANAESTHETIC   AGENTS   IN   EXTRACTION   OF  TEETH.         575 

and  especially  the  latter,  that  these  organs  are  not  only  free  from 
disease,  but  also  from  any  morbid  tendency,  as  ignorance  with  regard 
to  this  matter  might  lead  to  fatal  consequences.  It  should  be  given 
cautiously  under  any  circumstances,  and  the  pulse  should  never  be 
permitted  to  fall,  during  the  inhalation,  below  sixty,  or,  at  most,  fifty- 
five  beats  a  minute  ;  but  if,  from  carelessness,  or  any  other  cause,  the 
patient  should  sink  and  the  pulsation  cease,  the  agent  should  be  imme- 
diately removed  from  the  mouth,  and  if  occupying  a  sitting  posture, 
he  should  be  placed  in  a  reclining  position,  air  freely  admitted,  cold 
water  dashed  in  the  face,  the  feet  and  hands  rubbed  with  hot  salt  or 
mustard,  and,  if  necessary,  artificial  respiration  made  and  galvanism 
applied.  In  addition  to  these  means  the  tongue  should  be  depressed 
and  drawn  forward  by  a  finger  thrust  deeply  into  the  mouth,  as 
recommended  by  Ricord  ;  or  Marshall  Hall's,  or  Sylvester's  methods 
may  be  faithfully  and  jDatiently  practiced.  Ellis  gives  the  following 
simplified  formula  of  this  method  for  cases  of  asphyxia  from  drowning : 
"  Instantly  place  the  patient  on  the  face  and  side,  supporting  the  head. 
Unfasten  the  clothes  about  the  neck  and  chest,  braces,  etc.  Wipe  and 
clean  the  mouth  and  nostrils.  Raise  and  support  the  chest  on  a  folded 
coat  or  bundle.  Roll  the  patient  constantly  and  gently  from  the  face 
to  the  side,  and  back  again,  occasionally  changing  the  side,  supporting 
the  head.  On  the  completion  of  each  turn  to  the  face  make  a  brisk 
pressure  on  the  back,  between  and  below^  each  shoulder  blade.  Dry 
and  rub  the  patient  briskly,  rubbing  upward." 

The  inversion  of  the  body,  a  method  devised  by  the  celebrated  French 
surgeon,  Nelaton,  has  been  resorted  to  successfully.  Nitrite  of  amyl, 
a  powerful  stimulant,  has  been  successfully  inhaled  in  cases  of  chloro- 
form narcosis  with  dangerous  symptoms,  but  care  is  necessary  in  its 
use ;  and  not  more  than  i^ij  should  be  administered  by  inhalation  to 
persons  unaccustomed  to  its  effects. 

It  is  thought  by  those  who  have  had  most  experience  in  the  use  of 
ether  and  chloroform  as  ansesthetic  agents  that  their  administration 
is  attended  with  less  danger  when  the  patient  is  in  a  reclining  than 
when  in  a  sitting  posture.  It  would  be  well,  therefore,  when  either  is 
used  preparatory  to  the  extraction  of  teeth,  to  place  the  patient  as 
nearly  as  possible  in  such  a  position  ;  when  the  dentist  is  provided  with 
an  operating  chair  having  a  movable  back  this  can  be  very  readily 
done. 

Nitrous  Oxide  Gas  is  more  generally  employed  as  an  anaesthetic  in 
the  practice  of  dentistry  than  any  other,  and  the  immunity  from  acci- 
dent with  w'hich  it  is  administered  is  an  evidence  of  its  safety  when 
compared  with  chloroform  and  other  general  anaesthetics ;  due  care, 
however,  should  be  exercised  in  the  use  of  all  general  anaesthetics. 


576 


DENTAL,  SUEGERY. 


The  anaesthetic  effect  of  nitrous  oxide,  or  laughing  gas,  was  first 
suggested  by  Sir  Humphrey  Davy,  in  1776,  and  practically  demon- 
strated by  Dr.  Horace  Wells.  This  gas  is  manufactured  from  the  salt 
nitrate  of  ammonia,  either  in  a  fused  or  granulated  form,  by  slowly 


Fig.  407. 


melting  and  boiling  it  in  a  glass  retort,  over  a  sand  bath,  until  nearly 
all  of  the  nitrate  is  decomposed.  The  gas,  on  leaving  the  retort,  passes 
through  several  wash  bottles,  one  of  which  contains  either  a  solution  of 
the  sulphate  of  iron  or  caustic  potash,  and  the  other  two  pure  water, 


ANESTHETIC   AGENTS   IN   EXTRACTION   OF   TEETH. 


577 


for  the  purpose  of  purifying  it  before  it  enters  a  holder  and  receiver, 
from  which  it  is  administered  to  the  patient  by  means  of  an  inhaling 
tube.  One  pound  of  the  granulated  nitrate  of  ammonia  will  produce 
about  thirty  gallons  of  the  gas,  which  should  be  administered  to  the 
patient  in  a  pure  state — unmixed  with  atmospheric  air. 

Fig.  407  represents  an  apparatus  for  generating  nitrous  oxide  gas. 

Liquefied  Nitrous  Oxide  is,  however,  a  more  convenient  form  for  use. 

Fig.  408. 


To  obtain  this  form  the  nitrous  oxide  gas,  after  being  subjected  to 
intense  cold  and  pressure,  is  condensed  in  the  form  of  a  liquid,  in  a 
strong  iron  cylinder,  one  hundred  gallons  of  the  gas  weighing  but  ten 
pounds,  and  capable  of  being  condensed  into  a  cylinder. 

Fig.  408  represents  Downs'  stand  for  gas  cylinders,  for  use  in  the 
operating  room. 

Fig.  409  represents  an  upright  Surgeon's  Case,  of  a  convenient  and 
sightly  form,  with  bag  and  inhaler  attached. 

37 


578 


DENTAL  SURGERY. 


Fig.  410  represents  an  improved  Inhaler,  for  either  gas  or  ether ; 
when  it  is  desired  to  administer  ether,  the  end  tube,  to  which  the 
rubber  tubing  is  connected,  can  be  unscrewed,  and  the  globe,  which 
contains  a  sponge  to  hold  the  ether,  attached  in  its  stead. 

In  administering  this  gas  for  dental  operations,  the  patient  is  seated 
in  an  operating  chair  with  a  movable  back,  a  cork  or  piece  of  wood 
to  which  a  string  is  attached  placed  between  the  jaws,  or,  what  is  better, 
Bickfort's  mouth  prop,  which  is  in  the  form  of  a  telescope  slide  with 
blocks  of  rubber  at  the  ends,  to  act  as  cushions  to  protect  the  teeth  (Fig. 
411),  and  the  mouth-piece  of  the  inhaler  between  the  lips,  which  he  is 

Fig.  409. 


directed  to  close  tightly  around  it.  The  operator,  who  occupies  a  posi- 
tion on  the  right  side  of  the  patient,  supports  the  inhaler  with  his  right 
hand,  some  of  the  fingers  of  which  press  the  lower  lip  tightly  about  the 
mouth-piece.  The  thumb  and  index  finger  of  the  left  hand  close  the 
nostrils,  while  the  remaining  fingers  press  the  upper  lip  about  the  mouth- 
piece of  the  inhaler.  The  patient  is  then  instructed  to  make  long,  but 
at  the  same  time  natural,  inspirations,  one  of  the  valves  of  the  inhaler 
permitting  the  exhalations  to  pass  off". 

After  thus  inhaling  the  gas  for  a  few  minutes,  its  anjesthetic  effects 
are  shown  by  strong  involuntary  respirations  attended  by  a  snoring 


ANiESTHETIC   AGENTS   IN   EXTEACTION   OF   TEETH.         579 
Fig.  410.  Fig.  411. 


sound,  owing  to  the  relaxation 
of  tlie  muscles  of  the  pharynx. 
Then  folloAvs  a  livid  appearance 
of  the  lips,  from  the  discolored 
blood  in  the  capillaries.  A  spas- 
modic twitching  of  the  muscles 
is  observed  at  this  stage  in  many 
patients,  when  complete  narcosis 
follows.  The  narcotic  effects  of 
the  gas  continue  from  thirty 
seconds  to  one  and  a  half 
minutes,  and  the  number  of 
teeth  which  can  be  extracted 
varies  from  four  to  twelve.  It 
is  of  no  unusual  occurrence, 
however,  for  the  extraction  of 
one  tooth  to  consume  the  entire 
time  the  patient  is  under  the 
narcotic  influence  of  the  gas, 
while  in  other  cases,  more  than  the  highest  number  just  mentioned  may 
be  removed  before  the  patient  becomes  conscious  of  pain.  Nitrous 
oxide  gas  is  considered  to  be  the  safest  general  anaesthetic  now  in  use, 
and  does  not  produce  the  nauseating  and  debilitating  effects  which 
are  often  caused  by  ether  and  chloroform.  Extreme  caution,  how- 
ever, is  necessary  in  administering  this  gas  under  circumstances  which 
prohibit  the  use  of  other  general  anaesthetic  agents.     The  greatest  ob- 


580  DENTAL   SURGERY. 

jection  to  its  use,  aside  from  the  question  of  safety,  is  the  rapidity  in 
operating  which  its  transient  effect  necessitates;  and  it  is  much  better 
to  carefully  extract  a  few  teeth  than  to  attempt  the  removal  of  many 
by  an  operation  which  may  be  attended  with  severe  laceration  of  the 
gums  and  fracture  of  the  alveolus. 

Bromide  of  Ethyl. — Hydrobromic  ether  is  obtained  from  bromide  of 
potassium,  sulphuric  ether,  by  distillation,  and  by  re-distillation  with 
chloride  of  lime.  Although  a  pleasant  anaesthetic,  and  very  prompt 
in  its  eifect,  yet  its  administration  is  not  without  danger,  and  hence 
caution  is  necessary  in  its  employment.  It  is  administered  in  the  same 
manner  as  ether  or  chloroform,  and  recovery  from  its  influence  is  more 
rapid  than  with  either  of  these  agents.  From  thirty  seconds  to  five 
minutes  are  required  to  manifest  its  anaesthetic  effects.  The  quantity 
required  differs,  according  to  the  susceptibility  of  the  patient ;  the  usual 
rule  being  to  commence  with  one  drachm;  then  administer  a  second, 
and,  if  necessary,  a  third  drachm  may  be  inhaled  in  two  minutes  after 
the  administration  of  the  second  drachm.  Two  drachms  wi-ll,  however, 
in  most  cases,  be  sufficient  to  cause  a  profound  anaesthesia. 

Dr.  B.  W.  Richardson,  of  London,  introduced  an  anaesthetic  agent, 
known  as  the  bichloride  of  methylene,  which  is  formed  by  the  action  of 
sulphuric  acid  on  zinc  in  chloroform.  It  differs,  however,  from  chloro- 
form, in  the  circumstance  that  one  atom  of  chlorine  is  replaced  by  one 
atom  of  hydrogen.  Bichloride  of  methylene  produces  as  great  a  degree 
of  insensibility  as  chloroform,  and  its  action  is  more  rapid  and  the 
narcotism  very  prolonged.  It  also  interferes  less  with  muscular  irri- 
tability than  either  ether  or  chloroform,  and  the  recovery  from  its 
effects  is  sudden ;  but  more  of  it  is  required.  When  it  destroys  life, 
as  it  has  in  several  cases,  the  respiring  and  circulating  functions  are 
equally  paralyzed. 

Hydrate  of  chloral  is  another  general  anaesthetic  agent  which  has 
been  extensively  employed.  Chloral  is  by  no  means  a  new  anaesthetic, 
Liebig  having  discovered  it  in  1830 ;  but,  as  Dr.  B.  W.  Richardson 
states,  the  introduction  of  it  into  medicine  is  a  fact  of  the  present  year 
(1871),  its  introducer  being  Liebreich,  of  Berlin. 

The  hydrate  is  made  from  the  chloral  by  the  simple  addition  of  a 
little  water,  and  on  the  application  of  heat  solidifies  into  a  white  crys- 
talline substance. 

The  manner  in  which  hydrate  of  chloral  is  administered  is  in  solu- 
tion with  water,  either  by  the  mouth  directly  into  the  stomach,  or  by 
subcutaneous  injection.  The  best  solution  is  made  by  mixing  one  grain 
of  the  hydrate  with  two  of  water.  Dissolved  in  an  excess  of  water,  the 
taste  is  agreeable,  with  the  odor  of  a  ripe  melon.  It  is  administered 
to  human  subjects  in  doses  varying  from  twenty-five  to  thirty  grains, 


ANAESTHETIC    AGENTS    IN    EXTRACTION    OF   TEETH. 


581 


causing  unconsciousness  to  pain,  and  a  profound  sleep  lasting  over 
several  hours.  The  sleep  is  gentle  and  quiet,  induced  without  distress, 
and  leaving  no  other  symptom  behind  except  nausea,  which  is  occa- 
sionally experienced  after  recovery.  In  administering  this  agent,  it 
appears  to  act  more  promptly  when  subcutaneously  injected  than  when 
administered  directly  by  the  mouth ;  and  as  chloral  dissolved  in  water 
is  slightly  caustic,  it  cannot  be  administered  by  the  mouth  when  there 
are  lesions  of  mucous  membrane  or  ulcerated  tracts  of  intestinal  canal. 
In  administering  hydrate  of  chloral  to  the  human  subject,  Dr.  Richard- 
son states  that  allowance  will  have  to  be  made,  not  only  in  relation  to 
size  and  weight,  but  to  obesity  or  leanness,  to  natural  habit  and  actual 
state  of  body  in  respect  to  sensibility. 

Fig.  412  represents  the  full  size  of  a  hypodermic  syringe  with  gradu- 
ated rod  and  steel  points. 

Local  Anaesthetics. — Suspension  of  nervous  sensibility,  induced  by 
inhaling  the  vapor  of  ether,  chloroform,  nitrous  oxide,  bromide  of 
ethyl,  etc.,  is  general,  every  part  of  the  body  being  affected  alike ;  but 

Fig.  412. 


partial  or  local  anjBsthesia  may  be  procured  by  other  and  less  dan- 
gerous means.  Congelation  or  freezing,  first  proposed  and  employed 
in  the  Charite  Hospital,  Paris,  by  an  interne  of  M.  Velpeau,  and  sub- 
sequently recommended  by  Dr.  James  Arnott,  of  London,  has  been 
resorted  to  for  several  years,  both  by  surgeons  and  dentists,  and  prac- 
ticed, to  a  limited  extent,  with  some  success.  This  may  be  effected  by 
applying  a  mixture  of  pounded  ice  and  common  salt,  in  the  proportion 
of  two  or  three  parts  of  the  former  to  one  of  the  latter,  to  the  part  on 
which  the  operation  is  to  be  performed.  But  in  the  use  of  this,  care  is 
necessary  to  prevent  reducing  the  temperature  too  much,  as  in  this  case 
loss  of  vitality  would  be  occasioned  by  it.  We  have  heard  of  a  few 
cases  in  which  this  has  occurred,  but  we  believe  it  was  owing,  in  every 
instance,  to  carelessness  or  want  of  judgment  on  the  part  of  the  operator, 
as  to  the  length  of  time  the  application  of  the  mixture  should  be  con- 
tinued. 

Several  instruments  have  been  invented  for  the  application  of  the 


582  DENTAL  SUEGERY. 

freezing  mixture  to  teeth  preparatory  to  extraction.  The  one  which 
we  consider  best  adapted  for  the  purpose  was  designed  by  Dr.  Branch, 
of  Chicago,  111.  It  consists  of  a  hollow  tube,  about  an  inch  or  a  little 
more  in  diameter,  with  about  five-eighths  of  an  inch  cut  out  at  one  end, 
on  either  side,  that  it  may  readily  be  placed  over  a  tooth.  To  this  is 
attached  a  sac  of  finely-prepared  membrane,  large  enough  to  hold  a 
tablespoonful  of  the  mixture.  The  hollow  of  the  tube  is  occupied  by 
a  steel  wire  spiral  spring.  Just  before  using  it,  a  sufficient  quantity 
of  the  freezing  mixture  is  put  in  the  tube ;  the  end  of  the  latter  is 
placed  over  the  tooth,  when  the  ice  and  salt  are  forced  up  gently 
around  it  by  pressing  on  the  spring  at  the  other  extremity  of  the 
instrument.  Two  tubes  are  employed,  one  straight,  for  teeth  in  the 
anterior  part  of  the  mouth,  the  other  bent  near  one  end,  for  the  more 
convenient  application  of  the  mixture  to  a  molar  tooth. 

The  sudden  application  of  such  intense  cold  to  a  sensitive  tooth,  or 
to  one  which  has  not  lost  its  vitality,  is  often  productive,  at  first,  of 
severe  pain ;  on  this  account  many  object  to  the  use  of  it,  preferring 
the  momentary  suffering  consequent  upon  the  operation  of  extraction 
than  that  occasioned  by  the  freezing  mixture.  But  this  effect  is  rarely 
experienced  in  its  use  on  dead  teeth,  or  the  roots  of  teeth  which  have 
lost  their  vitality  ;  hence,  the  application  of  it  has  to  such  proved  more 
satisfactory  than  to  living  teeth. 

With  the  view  of  obviating  the  above  objection  to  the  use  of  cold 
as  an  ausesthetic  agent,  Messrs.  Home  and  Thornthwaite,  opticians, 
at  the  suggestion  of  Mr.  Blundell,  dentist,  of  London,  contrived  and 
constructed  an  apparatus,  by  which  the  temperature  may  be  gradually 
diminished ;  say  from  98°,  or  blood  heat,  down  to  zero,  or  any  required 
degree,  thus  preventing  the  pain  consequent  upon  the  sudden  applica- 
tion of  the  freezing  agent.  The  apparatus  is  thus  described :  "  The 
required  amount  of  water  is  cooled  down,  by  means  of  ice  and  salt,  to 
about  zero,  in  a  vessel  called  the  refrigerator.  To  this  vessel  is  attached 
another,  called  a  graduator,  containing  warm  water  at  about  100°,  and 
so  constructed  as  to  allow  the  slow  admixture  of  its  contents  with  the 
chilled  water  in  the  refrigerator,  and  thus  produce  a  gradually  dimin- 
ishing temperature,  for  the  purpose  of  preventing  sudden  shock  and 
pain  to  the  teeth,  which  a  direct  application  of  cold  would  inevitably 
cause.  A  tube  conveys  this  graduating  current  into  a  terminal  portion, 
constructed  of  very  fine  membrane,  Avhich  adapts  itself  to  the  form  of 
the  gums,  and  wholly  surrounds  the  tooth  to  be  withdrawn.  The  fluid 
then  passes  away  through  an  exit  tube.  In  this  manner  a  constant 
current  of  cold,  at  a  decreasing  temperature,  is  made  to  pass  over  the 
part,  abstracting  therefrom  all  heat,  and  with  it  the  power  of  feeling." 
The  gum  and  alveolar  membrane  being  now  in  a  frozen  condition,  and. 


ANAESTHETIC   AGENTS   IN    EXTRACTION   OF  TEETH.         583 

consequently,  devoid  of  sensibility,  the  extracting  instrument  is  applied 
and  the  tooth  removed. 

In  the  early  part  of  the  year  1858,  Mr.  J.  B.  Francis,  dentist,  of 
Philadelphia,  announced  the  discovery  of  an  original  method  of  pro- 
ducing local  anaesthesia,  said  to  be  peculiarly  applicable  to  the  extrac- 
tion of  teeth,  which  consists  in  passing  an  electro-galvanic  current 
through  the  tooth  at  the  moment  of  its  removal.  The  discovery  was 
submitted  to  the  Franklin  Institute,  Philadelphia,  and  the  committee 
to  whom  it  was  referred  for  examination,  composed  in  part  of  dentists, 
reported  favorably  in  regard  to  the  claims  of  the  inventor.*  One  of 
the  members  of  this  committee,  W.  S.  Wilkinson,  states  that  he  had 
extracted  between  four  and  five  hundred  teeth,  applying  the  electric 
current ;  and  that  in  ninety-five  per  cent,  of  the  cases  it  was  done 
without  pain  to  his  patient. 

The  method  of  applying  it  is  very  simple.  One  pole  (the  negative 
is  preferable)  of  the  electro-galvanic  machine  is  attached  to  one  of  the 
handles  of  the  forceps  by  means  of  a  flexible  conductor,  while  the 
metallic  handle  of  the  other  is  grasped  by  the  patient ;  the  power  of 
the  current  being,  previously  to  the  operation,  graduated  by  the  piston 
of  the  coil,  while  the  patient  holds  the  forceps  in  the  other  hand.  The 
current  should  only  be  sufficiently  powerful  to  be  distinctly  felt.  The 
circuit  through  the  tooth  is  not  made  until  at  the  instant  the  operation 
begins.  The  closing  and  breaking  of  the  galvanic  circuit  is  managed 
either  by  the  foot  of  the  operator  or  by  an  assistant. 

A  small  electro-galvanic  battery,  arranged  for  this  purpose,  having 
been  placed  in  the  office  of  the  author  soon  after  the  announcement 
of  the  discovery,  he  has  had  frequent  opportunities  of  applying  this 
new  agent  in  the  extraction  of  teeth.  Thus  far,  about  nine  out  of  ten  of 
those  who  were  placed  under  its  influence  while  undergoing  the  opera- 

*  The  following  is  an  extract  from  the  report  referred  to  above  :  "  The  com- 
mittee is  satisfied,  from  the  observation  and  experiment  of  its  members,  that  in 
a  large  majority  of  cases  of  extraction  with  this  apparatus,  no  pain  ivhatever  is 
felt  by  the  patient. 

"To  test  the  question  whether  the  effect  might  not  be  simply  mental,  the  cir- 
cuit was  broken  without  the  patient  being  aware  of  it,  when  the  usual  pain  was 
experienced,  although,  in  the  same  patient  and  on  the  same  occasion,  teeth  had 
been  removed,  while  the  current  was  flowing,  without  causing  pain. 

"  In  the  less  successful  cases,  the  teeth  were  broken  and  diseased  below  the 
level  of  the  gum,  and  the  pain,  in  adjusting  the  forceps,  previous  to  the  comple- 
tion of  the  circuit  and  the  extraction,  was  considerable. 

"  The  sensation  produced  by  the  passage  of  the  current  is  not  painful,  it  being 
so  adjusted  as  to  be  just  perceptible  to  the  patient.  The  committee  believes  its  use 
to  be  entirely  without  danger,  and  not  likely  to  be  followed  by  any  unpleasant 
after  effects." 


584  DENTAL   SURGERY. 

tion  assured  him  that  they  either  experienced  no  pain  at  all,  or  only 
very  little — not  a  tenth  part  of  what  they  had  experienced  under  the 
operation  on  former  occasions.  In  almost  every  case  in  which  the  tooth 
was  grasped,  allowing  the  instrument  to  come  in  contact  with  only  the 
edge  of  the  gum,  the  operation  appeared  to  be  painless,  or  nearly  so. 
But  when  pushed  up  a  considerable  distance  between  it  and  the  tooth, 
the  suffering  was  not  appreciably  diminished,  the  electric  current  in 
such  cases  seeming  to  be  too  much  diffused.  It  is  stated  by  those  who 
have  made  the  experiment,  that  this  diffusion  of  the  electric  current 
may  be  prevented  by  insulating  the  outer  portion  of  the  instrument 
with  a  coating  of  gutta-percha,  or  by  japanning.  The  author  has  not 
tried  this  expedient. 

How  it  is  that  the  passage  of  an  electric  current  through  a  tooth 
should  prevent  pain  may  be  explained  by  supposing  the  subtle  fluid  to 
(Bxhaust  the  sensibility  of  the  nerves  of  the  parts  comprised  in  the  opera- 
tion; and  that  it  does,  in  a  majority  of  cases,  is  attested  by.  many  who 
have  been  placed  under  its  influence.  It  may  be  nothing  more  than  a 
mere  substitution  of  one  sensation  for  another ;  but  whether  its  appli- 
cation will  become  general,  or  its  eflScacy  as  an  anaesthetic  agent  be 
fully  established,  remains  for  future  experience  to  settle. 

The  experience  of  the  profession  may  be  briefly  summed  up  thus  : 
In  one-fourth  the  cases  it  relieves  or  neutralizes  the  peculiar  pain  of 
extraction,  in  one-half  it  has  but  little  effect,  and  in  the  remaining 
fourth  it  very  decidedly  aggravates  the  pain.  It  has,  however,  the 
advantage  over  chloroform  and  the  freezing  process,  of  being  without 
any  serious  sequelae. 

Dr.  B.  W.  Richardson  also  introduced  a  much  more  speedy  and 
effectual  method  of  congelation  than  those  before  described,  by  taking 
advantage  of  the  intense  cold  occasioned  by  the  rapid  evaporation  of 
ether  spray  when  forced  through  one  of  the  instruments  invented  for 
the  atomization  of  fluids. 

"  The  principle,"  Dr.  Richardson  remarks,  "  consists  in  directing  on 
a  part  of  the  body  a  volatile  liquid,  having  a  boiling  point  at  or  below 
blood  heat,  in  a  state  of  fine  subdivision  or  spray,  such  subdivision  being 
produced  by  the  action  of  air,  or  other  gaseous  substance,  on  the  vola- 
tile liquid  to  be  dispersed.  When  the  volatile  fluid,  dispersed  in  the 
form  of  spray,  falls  on  the  human  body,  it  comes  with  force  into  the 
most  minute  contact  with  the  surface  upon  which  it  strikes.  As  a 
result  there  is  rapid  evaporation  of  the  volatile  fluid,  and  so  great  an 
evolution  of  heat  force  from  the  surface  of  the  body  struck,  that  the 
blood  cannot  supply  the  equivalent  loss.  The  part  consequently  dies 
for  the  moment,  and  is  insensible  as  in  death ;  but  as  the  vis-a-tergo 
of  the  body  is  unaflfected,  the  blood,  as  soon  as  the  external  reducing 


ANESTHETIC   AGENTS    IN   EXTRACTION   OF   TEETH. 


585 


agency  is  withdrawn,  quickly  makes  its  way  again  through  the  dead 
parts,  and  restoration  is  immediate.  The  extreme  rapidity  of  the  action 
of  this  deadening  process  is  the  cause  of  its  safety." 

Fig.  413  represents  the  apparatus,  which  consists  of  a  spray-tube, 
bottle,  and  hand  bellows,  for  producing  local  anaesthesia  by  narcotic 
spray. 

Either  absolute  ether  or  rhigolene  may  be  employed,  both  of  which 
are  highly  inflammable.  Some  prefer  rhigolene,  on  account  of  its  action 
being  more  prompt  than  that  of  the  ether,  while  others  consider  the 
latter  more  agreeable  and  easily  controlled.  To  produce  the  local 
anaesthetic  effect  with  these  agents  in  the  form  of  spray  requires  from 
thirty  to  sixty  seconds.  Before  the  application  of  the  spray,  the  crown 
of  the  tooth  to  be  extracted  and  mucous  membrane  over  the  root  should 
be  carefully  dried,  otherwise  a  film  of  ice  may  be  formed  which  will 
prevent  the  full  influence  of  the  agent,  such  as  is  shown  by  the  blanching 
of  the  gum. 

Fig.  413. 

A. 


Local  bloodletting,  such  as  follows  lancing  of  the  gums,  prior  to  the 
application  of  the  spray  is  said  to  prevent  desquamation. 

Obtunding  mixtures,  consisting  of  a  combination  of  pyrethrum, 
aconite,  chloral,  veratria  and  alcohol,  or  chloroform,  aconite,  belladonna 
and  opium,  have  been  employed  to  produce  local  ansesthesia,  and  in 
many  cases  with  satisfactory  results.  For  although  entire  insensibility 
to  pain  cannot,  in  all  cases,  be  brought  about,  yet  some  diminution  of 
it  may  be  effected  by  the  use  of  such  agents.  They  have  the  merit,  at 
least,  of  being  less  dangerous  than  the  general  ansesthetics.  Such 
pain-obtunding  mixtures  are  best  applied  to  the  parts  about  the  neck 
and  over  the  root  of  a  tooth  by  means  of  a  simple  apparatus  devised 
by  Von  Bonhorst.  It  consists  of  two  small  metallic  cups  attached  to 
the  free  ends  of  a  spring  some  seven  inches  long,  and  which  contain 
sponges  to  hold  the  liquid.     (Fig.  414. ) 


586  DENTAL   SURGERY. 

When  used,  the  sponges  in  the  cup  are  saturated  with  the  obtunding 
mixture  and  applied  by  pressing  them  on  the  gum  on  each  side  of  the 
tooth  to  be  removed,  where  they  are  retained  from  one-half  to  two 
minutes.  Previous  to  the  application,  the  patient  should  be  cautioned 
against  swallowing  any  portion  of  the  mixture. 

A  new  local  anaesthetic,  known  as  hydrochlorate  of  cocaine  (CnH.^i 
NOJ,  has  been  recently  discovered  and  applied  in  Germany,  with 
astonishing  and  satisfactory  results,  in  operations  upon  the  eye.  Prof. 
Gorgas  has  experimented  with  this  new  ansesthetic  in  cases  of  sensitive 
dentine  and  the  extirpation  of  the  pulps  of  teeth  by  the  surgical 
method,  with  very  satisfactory  results.  The  two  or  four  per  cent 
solution,  made  with  distilled  water  and  with  Merck's  hydrochlorate  of 
cocaine,  may  be  used,  a  drop  of  the  solution  being  applied  to  the 
sensitive  surface  three  times,  at  intervals,  during  a  period  of  ten  or 
fifteen  minutes  ;  at  the  end  of  twenty-five  minutes  a  very  satisfactory 
condition  of  ansesthesia  is  caused.  Cocaine  is  the  alkaloid  of  the 
leaves  of  the  erythroxylon  coca,  a  shrub  of  South  America,  and  has 

Fig.  414. 


long  been  used  by  the  natives  of  Peru  and  Bolivia  as  a  nerve  stimu- 
lant. Small  animals  have  been  killed  by  its  causing  paralysis  of  the 
respiratory  centres. 

Dr.  J.  A.  Robinson  has  recently  suggested  carbolized  potash  (equal 
parts  of  caustic  potash  and  carbolic  acid)  as  a  local  ansesthetic  or 
obtunder  in  cases  of  sensitive  dentine, 

Eapid  Breathing  as  a  Fain  Obtunder. — The  possibility  of  producing 
an  ansesthetic  effect  by  rapid  breathing  was  suggested  by  Dr.  W.  G.  A. 
Bon  will,  in  1875.  By  this  method  it  is  claimed  that  teeth  may  be  ex- 
tracted without  pain.  In  applying  it  the  patient  should  rest  upon  the 
side,  and  in  as  reclining  a  position  as  is  possible  to  operate,  A  hand- 
kerchief is  then  placed  over  the  face,  to  insure  quiet,  and  directions  are 
given  to  breathe  rapidly  at  the  rate  of  about  one  hundred  respirations 
per  minute — blowing-out  movement.  At  the  end  of  from  tAvo  to  five 
minutes  of  such  rapid  breathing,  it  is  claimed  that  an  entire,  or  at 
least  partial,  state  of  anaesthesia  results,  which  may  continue  for  a  half 
or  for  one  or  two  minutes.    This  method  is,  apparently,  a  harmless  one. 


REPLANTATION   AND   TRANSPLANTATION   OF   TEETH.       587 

but  some  have  connected  with  it  such  a  clanger  as  venous  congestion  of 
the  brain.  Females  appear  to  be  more  susceptible  to  this  method  than 
males,  and  children  under  ten  years  of  age  can  rarely  be  induced  to 
breathe  properly. 

As  the  use  of  anaesthetic  agents  of  any  kind  in  the  extraction  of  teeth 
is  attended  with  inconvenience,  nearly  always  delaying  the  operation, 
the  author  is  of  opinion  that  their  employment,  as  a  general  thing, 
should  be  dispensed  with.  In  the  case  of  females  with  a  highly 
nervous  organization,  it  may  now  and  then  be  advisable  to  give  a  tem- 
porary courage  to  endure  pain  by  the  administration  of  a  teaspoonful  of 
brandy.  But  we  have  found  less  trouble  with  delicate  females  than  with 
stalwart  men  ;  and  to  the  latter  we  certainly  would  never  advise  this  use 
of  stimulants.  Indeed,  the  extraction  of  a  tooth  is,  in  the  majority  of 
cases,  so  simple  an  operation,  seldom  requiring  more  than  from  two  to 
five  seconds  for  its  performance,  that  most  persons  should  rather  sub- 
mit to  it  at  once,  than  have  it  protracted  by  the  application  of  an 
agent  for  the  prevention  of  the  momentary  pain  which  it  occasions. 


CHAPTER  VII. 

REPLANTATION   AND   TRANSPLANTATION   OF   TEETH. 

CLOSELY  connected  with  the  subject  of  extraction  of  teeth  are 
Replantation  and  Transplantation,  which  appear  to  have  been 
practiced  several  centuries  ago,  both  in  France  and  Germany. 

Later,  both  of  these  operations  attracted  the  attention  of  John 
Hunter,  in  England,  and  some  interesting  experiments  were  made  by 
him  in  transplanting  teeth,  although  he  did  not  advocate  the  latter 
practice. 

The  operation  of  "replantation"  consists  in  the  return  of  a  tooth  to 
the  same  cavity  from  which  it  has  been  extracted,  and  also  the  neces- 
sary antiphlogistic  treatment  which  will  result  in  the  re- establishment 
of  the  connection  which  originally  existed  between  the  tooth  so  returned 
and  its  cavity.  Replantation  is  performed  where  a  tooth  has  been 
accidentally  removed,  and  also  for  the  cure  of  alveolar  abscess,  more 
'especially  such  cases  where  the  extreme  end  of  the  root  is  aflected  with 
abscess,  and  a  considerable  portion  of  the  investing  membrane  or  peri- 
osteum is  in  a  healthy  condition.  Under  such  circumstances  the  opera- 
tion of  replantation  may  be  performed  as  follows :  The  tooth  is  to  be 
very  carefully  extracted,  and  at  once  placed  in  warm  water,  to  which 


588  DENTAL,  SURGERY. 

a  little  tincture  of  iodine  has  been  added.  The  cavity  from  which  the 
tooth  has  been  removed  should  be  carefully  and  gently  wiped  out  with 
a  cone  of  soft  Japane'^e  paper,  wrapped  about  the  end  of  an  excavator 
or  other  suitable  instrument,  to  remove  any  shreds  of  the  abscess  sac 
that  may  remain  attached  to  its  walls,  and  a  delicate,  spear-shaped, 
nerve  instrument  passed  through  the  alveolus,  to  detach  the  cyst.  The 
cavity  is  then  syringed  with  warm  water,  and  packed  lightly  with 
cotton  saturated  with  tincture  of  iodine. 

When  this  is  accomplished,  attention  is  again  given  to  the  tooth,  from 
which  all  traces  of  the  abscess  sac  should  be  removed,  as  well  as  salivary 
calculus,  if  present,  care  being  taken,  however,  not  to  injure  or  remove 
any  healthy  periosteum  that  may  remain  attached  to  the  root.  The 
pulp  chamber  is  then  to  be  exposed,  and,  with  the  root  canals,  thor- 
oughly cleansed  and  disinfected,  and  filled  to  the  apex  with  gold  or 
other  suitable  material.  The  packing  is  then  carefully  removed  from 
the  cavity,  which  is  again  syringed  with  warm  water,  and  the  tooth 
firmly  pressed  into  its  former  position,  and  held  there  for  a  few  moments 
with  the  fingers.  The  mouth  may  then  be  rinsed  with  an  astringent 
mouth  wash,  and  the  tooth  secured  by  ligatures,  or,  with  what  answers 
better,  a  cap  of  modeling  composition  or  gutta  percha.  The  mouth 
should  be  rinsed  with  an  astringent  wash,  three  or  four  times  daily,  and 
be  kept  thoroughly  clean. 

The  following  mouth  washes,  from  Gorgas'  Dental  Medicine,  will 
prove  useful : — 

K.     Acidi  carbolic!  (crjst.) 

Glycerini  and  aquse  rosse aa ^'\].     M. 

SiG. — Five  to  eight  or  ten  drops  in  a  wineglass  of  water. 

R.     Tincturse  arnicse ^ij 

Glycerini 3ij 

Aquag^rosae ,^  ij 

Aquse  destillatse ^  x.     M. 

SiG. — To  be  used  as  a  gargle- 
Where  the  apex  of  the  root  of  the  tooth  is  necrosed,  this  portion 
should  be  excised  and  made  smooth  before  the  tooth  is  returned  to 
its  cavity,  the  same  treatment  as  above  described  being  pursued. 
When  a  replanted  tooth  has  been  returned  to  its  cavity,  the  lymph 
present  either  coagulates  and  becomes  organized,  so  that  no  pus  is 
formed,  which  is  the  process  of  healing  by  "first  intention;"  or  the 
lymph  may  degenerate  into  pus,  in  which  latter  case  the  operation 
may  prove  a  failure.  To  obviate  such  a  condition,  it  has  been  sug- 
gested to  make  an  opening  through  the  alveolus  to  the  apex  of  the 
root  of  the  tooth,  and,  by  means  of  floss  silk  or  a  pledget  of  cotton, 


REPLANTATION   AND   TRANSPLANTATION   OF   TEETH.       589 

to  establish  a  drainage ;  or  to  insert  a  drain  tube  from  the  surface  of 
the  crown  through  the  canal  to  the  apex  of  the  root. 

The  operation  of "  transplantation"  consists  in  the  extraction  of  a 
tooth  from  the  mouth  of  one  person  and  transferring  it  to  a  cavity  in 
the  mouth  of  another;  in  some  cases  the  teeth  of  animals  have  been 
substituted  for  human  teeth. 

The  defective  tooth  is  first  extracted,  and  having  previously  selected 
a  tooth  in  the  mouth  of  another,  which  will  correspond  in  size,  color, 
location  and  other  characteristics,  it  is  carefully  extracted  and  imme- 
diately transferred  to  the  cavity  from  which  the  defective  tooth  has 
been  removed,  as  soon  as  the  hemorrhage  has  ceased.  When  the  tooth 
to  be  transplanted  is  of  a  different  form  from  the  one  it  is  to  replace,  it 
must  be  made  to  correspond  to  the  new  cavity  by  properly  changing 
its  dimensions,  a  procedure  that  would  not  be  possible,  to  the  same 
degree  at  least,  in  the  case  of  replantation,  for  many  examples  are  pre- 
sented of  dried  teeth  having  been  successfully  transplanted.  The 
operation  of  transplantation  is  completed  by  securing  the  new  tooth  in 
position  and  employing  the  necessary  antiphlogistic  treatment  as  in 
replantation.  Such  teeth,  however,  never  perfectly  harmonize  with 
their  new  relation,  and  when  a  dried  tooth  is  used  its  pulp  canal  should 
be  previously  filled  with  gold.  It  is  also  suggested  to  excise  a  portion 
of  the  end  of  the  tooth,  from  one-sixteenth  to  one-eighth  of  an  inch,  and 
to  separate,  by  a  non-conducting  substance,  the  root  filling  from  that  in 
the  crown,  and,  as  in  the  ease  of  replantation,  to  prescribe  an  unstimu- 
lating  diet.  In  the  operation  of  replantation,  we  depend  for  success 
upon  a  reattachment  of  the  periosteum  ;  but  in  the  case  of  ti-ansplanta- 
tion,  and  especially  where  dried  teeth  are  made  use  of,  stability  is  due 
to  absorption  of  the  dead  tissue  on  the  one  hand  and  a  corresponding 
hypertrophy  of  living  tissue  on  the  other,  the  root  of  the  tooth  under- 
going loss  of  structure  in  the  form  of  small  cavities,  and  the  wall  of 
the  alveolar  cavity  thickened  by  ossific  deposit  at  points  corresponding 
to  the  cavities  formed  in  the  dead  tissue  of  the  root.  And  while  it  may 
require  one  week  for  a  replanted  tooth  to  become  firm,  two  or  more 
may  be  necessary  in  the  case  of  a  transplanted  tooth.  For  retaining 
replanted  and  transplanted  teeth  in  position,  either  the  modeling  com- 
position and  gutta-percha  splints  before  alluded  to  may  be  employed* 
or  the  ingenious  device  of  Dr.  Herbst,  which  is  represented  by  Fig.  176 
(p.  397).  An  interdental  splint  of  either  modeling  composition  or  red 
gutta-percha  pressed,  while  soft,  over  the  newly-placed  tooth,  and  the 
teeth  of  both  jaws  brought  in  contact  and  pressed  slightly  into  the 
plastic  mass  will  also  prove  eflTectual  as  a  retaining  appliance. 

While  the  operation  of  "  replantation"  is  a  justifiable  one,  that  of 
"transplantation"  is  objectionable,  for  several  reasons,  namely:  the 


590  DENTAL   SURGERY. 

necrosed  condition  of  such  a  tooth,  and,  as  a  consequence,  its  uncertain 
duration  ;  the  liability  to  failure ;  the  liability  of  inoculation  by  the 
transmission  of  disease  ;  and  the  inhumanity  of  inflicting  loss  and  pain 
on  one  person  in  order  to  give  another  a  very  uncertain  advantage. 


CHAPTER  VIII. 

DISLOCATION   AND   FRACTURE   OF   THE   JAW. 

FROM  the  peculiar  manner  in  which  the  inferior  maxilla  is  articu- 
lated to  the  temporal  bones,  it  is  not  very  liable  to  dislocation. 
When  it  occurs  in  one  or  both  of  the  condyles,  the  luxation  is  always 
forward,  the  conformation  of  the  parts  preventing  it  from  taking  place 
in  any  other  direction.  The  oblong,  rounded  head  of  each  condyle  is 
received  into  the  fore  part  of  a  deep  fossa  in  the  temporal  bone,  situ- 
ated just  before  the  meatus  auditorius  externus,  and  under  the  begin- 
ning of  the  zygomatic  arch.  The  articular  surface  of  each  is  covered 
with  a  smooth  cartilage,  and  between  them  there  is  a  movable  carti- 
lage. This  latter  is  connected  with  the  articulating  surfaces  of  the 
condyle  and  glenoid  cavity,  externally  by  the  external  lateral  liga- 
ment, internally  by  the  capsular  ligament,  and  in  front  by  the  tendon 
of  the  external  pterygoid.  This  cartilage  is  sometimes  called  the 
meniscus,  from  its  shape,  being  thickest  around  its  circumference, 
especially  at  the  back  part.  The  temporo-maxillary  articulation  is 
strengthened  by  an  internal,  an  external,  and  a  capsular  ligament, 
also  by  the  tendinous  and  muscular  insertions  of  the  masseter,  tem- 
poral and  pterygoid  muscles.  The  intervening  movable  cartilage,  being 
more  closely  connected  with  the  head  of  the  condyle  than  with  the 
glenoid  cavity,  escapes  with  the  former,  whenever  dislocation  of  the 
jaw  takes  place. 

Dislocation  of  the  lower  jaw  is  rarely  caused  by  a  blow,  unless  given 
when  the  mouth  is  open  ;  it  is  more  frequently  occasioned  by  yawning 
or  laughing.  It  has  been  known  to  occur  in  the  extraction  of  teeth, 
and  in  attempting  to  bite  a  very  large  substance.  Sir  Astley  Cooper 
mentions  the  case  of  a  boy  who  had  his  jaw  dislocated  by  suddenly 
putting  an  apple  into  his  mouth  to  keep  it  from  a  playfellow. 

After  the  jaw  has  been  dislocated  once,  it  is  always  more  liable  to 
this  accident;  consequently,  Mr.  Fox  very  properly  recommends  to 
those  with  whom  it  has  once  happened  the  precaution  of  supporting 
the  jaw  whenever  the  mouth  is  opened  very  widely  in  gaping,  or  for 


DISLOCATION   AND    FRACTURE   OF   THE   JAW. 


591 


Fig   415. 


the  purpose  of  having  a  tooth  extracted.  None  of  these  causes  would 
be  sufficient  to  produce  the  accident,  unless  the  ligaments  of  the  tem- 
poro-maxillary  articulation  are  very  loose,  and  the  muscles  of  the  jaw 
much  relaxed. 

The  author  witnessed  a  case  of  dislocation  of  the  lower  jaw  in  which 
the  displacement  occurred  during  an  attempt  to  extract  the  first  right 
inferior  molar.  The  patient  was  a  young  lady  from  Virginia,  about 
seventeen  years  of  age.  Both  condyles  were  luxated,  but  so  completely 
were  the  muscles  of  the  jaw  relaxed,  that  he  ir^mediately  reduced  it 
without  the  least  difficulty,  and  afterward,  by  supporting  the  jaw  with 
his  left  hand,  succeeded  in  removing  the  tooth. 

When  the  lower  jaw  is  dislocated,  the  mouth  remains  wide  open,  as 
seen  in  Fig,  415,  and  a  great  deal  of  pain  is  experienced ;  this,  according 
to  Boyer,  is  caused  by  the  pressure  of 
the  condyles  on  the  deep-seated  tem- 
poral nerves  and  those  which  go  to 
the  masseter  muscles,  situated  at  the 
root  of  the  zygomatic  process.  The 
condyles,  having  left  their  place  of 
articulation,  are  advanced  before  the 
articular  eminences  and  lodged  under 
the  zygomatic  arches.  The  jaw  can- 
not be  closed  ;  the  coronoid  processes 
may  be  felt  under  the  malar  bones ; 
the  temporal,- masseter  and  buccinator 
muscles  are  extended ;  the  articular 
cavities  being  empty,  a  hollow  may  be 
felt  there ;  the  saliva  flows  uninter- 
ruptedly from  the  mouth,  and  deglu- 
tition and  speech  are  either  wholly  prevented  or  very  greatly  impaired. 
Boyer  says  that  during  the  first  five  days  after  the  accident  the  patient 
can  neither  speak  nor  swallow.  The  jaw,  when  only  one  condyle  is 
displaced,  is  forced  more  or  less  to  one  side. 

If  the  dislocation  continues  for  several  days  or  weeks,  the  chin 
gradually  approaches  the  upper  jaw,  and  the  patient  slowly  recovers 
the  functions  of  speech  and  deglutition.  We  are  told  by  Mr.  Samuel 
Cooper  that  it  may  prove  fatal  if  it  remains  unreduced;*  but  Sir  Astley 
Cooper  says  he  has  never  known  any  dangerous  effects  to  result  from 
this  accident ;  on  the  contrary,  after  it  has  continued  for  a  considerable 
length  of  time,  the  jaw  partially  recovers  its  motion. f 

In  the  reduction  of  dislocation  of  the  lower  jaw,  the  older  surgeons 
employed  two  pieces  of  wood,  which  were  introduced  on  each  side  of 

*  Surgical  Dictionary,  p.  306,  f  A,  Cooper  on  Dislocations,  p.  389, 


592  DENTAL   SURGERY. 

the  mouth,  between  the  molar  teeth;  while  these  were  made  to  act  as 
levers  for  depressing  the  back  part  of  the  bone,  the  chin  was  raised  by 
means  of  a  bandage. 

The  method  usually  adopted  by  modern  surgeons  for  reducing  a 
dislocation  of  this  bone  consists  in  introducing  the  thumbs,  wrapped 
in  a  napkin  or  cloth  (to  prevent  them  from  being  hurt  by  the  teeth), 
as  far  back  upon  the  molars  as  possible ;  then  depressing  the  back 
part  of  the  jaw,  and  at  the  same  time  raising  the  chin  with  the  fingers. 
In  this  way  the  conchies  are  disengaged  from  under  the  zygomatic 
arches,  and  made  to  glide  back  into  their  articular  cavities.  But  the 
moment  the  condyles  are  disengaged,  the  thumbs  of  the  operator  should 
be  slipped  outward  between  the  teeth  and  the  cheeks,  as  the  action  of 
the  muscles  at  this  instant,  in  drawing  the  jaw  back,  causes  it  to  close 
very  suddenly,  and  with  considerable  force.  This  precaution  is  neces- 
sary to  avoid  being  hurt,  unless  a  piece  of  cork  or  soft  wood  has  been 
previously  placed  between  the  teeth. 

By  the  foregoing  simple  method  the  dislocation  may,  in  almost  every 
case,  be  readily  reduced ;  but  Mr.  Fox  mentions  a  case  in  which  it 
failed.  The  subject  was  a  lady  whose  lower  jaw  had  been  luxated 
several  times  before ;  this  time  the  accident  was  occasioned  by  an 
attempt  which  he  made  to  extract  one  of  the  inferior  dentes  sapientise. 
After  having  failed  to  reduce  the  luxated  bone  by  the  usual  method, 
he  "happened  to  recollect  a  statement  made  to  him  by  M.  de  Chemant, 
who,  having  been  frequently  applied  to  by  a  person  in  Paris  who  was 
subject  to  this  accident,  had  always  succeeded  in  immediately  reducing 
the  luxation  by  means  of  a  lever  of  wood,  as  recommended  by  Dr. 
Monroe."  Profiting  by  this  statement,  Mr.  Fox  procured  a  piece  of 
wood,  about  an  inch  square  and  ten  or  twelve  inches  long.  He  placed 
one  end  of  this  upon  the  lower  molars,  and  then  raised  the  other,  so 
that  the  upper  teeth  acted  as  a  fulcrum.  As  soon  as  the  jaw  was 
depressed,  the  condyle  of  the  side  upon  which  the  wood  was  applied 
immediately  slipped  back  into  its  articular  cavity.  The  wood  was 
then  applied  to  the  opposite  side  of  the  jaw,  and  the  other  condyle 
reduced  in  the  same  manner.* 

The  method  produced  by  Sir  Astley  Cooper  consists,  when  both 
condyles  are  displaced,  in  introducing  two  corks  behind  the  molars, 
and  then  elevating  the  chin.  He,  however,  first  places  his  patient  in 
a  recumbent  posture  ;t  but  this  is  seldom  necessary.  The  reduction 
of  the  dislocation  can  be  as  conveniently  efiected  with  the  patient  in  a 
sitting  as  in  a  recumbent  posture. 

After  the  reduction  of  the  dislocation,  the  patient  is  recommended 

*  American  edition  of  Fox  on  the  Human  Teeth,  p.  330. 
f  A.  Cooper  on  Dislocations,  p,  391. 


DISLOCATION   AND   FRACTUEE   OF   THE   JAW.  593 

to  abstain  for  several  days  from  the  use  of  solid  aliments,  and  to  wear 
a  four-tailed  bandage  ;*  or,  what  is  still  better,  the  bandage  contrived 
by  Mr.  Fox  (Fig.  196,  p.  405),  to  prevent  its  recurrence  in  the  extrac- 
tion of  teeth.  When  this  bandage  is  used  for  the  latter  purpose,  the 
mouth  is  first  opened  to  the  proper  extent,  with  the  condyles  in  their 
articular  cavities ;  it  is  then  applied,  and  the  straps  tightly  buckled. 
This  done,  it  is  impossible  to  advance  the  jaw  sufficiently  to  produce  a 
dislocation. 

FRACTURES   OF   THE   JAWS. 

Fractures  of  the  jaws  rarely  occur,  except  from  direct  violence.  In 
the  upper  jaw  this  violence  is  usually  of  a  character  that  complicates 
the  fracture  with  severe  injury  to  adjacent  parts.  Gunshot  wounds 
are  by  far  the  most  frequent  source  of  fractures  in  this  locality;  and  it 
is  wonderful  what  an  amount  of  injury  to  the  bones  of  the  face  may  be 
recovered  from  without  ill  result.  The  bones  of  the  face  are  of  softer 
character  than  those  found  elsewhere,  and  consequently  the  whole 
injury  is  at  the  place  of  impact  and  along  the  course  of  the  ball;  no 
long  fractures  or  extensive  contusions  are  found,  or  very  rarely  so,  and 
the  parts  are  abundantly  supplied  with  blood,  hence  the  restorative 
process  proceeds  very  rapidly;  but  this  abundant  sanguineous  supply, 
so  useful  in  the  restoration  of  parts,  is  also  the  chief  source  of  danger. 
Hemorrhage  is  generally  excessive  and  difficult  to  control,  and  to  sec- 
ondary hemorrhage  is  due  the  greatest  fatality  in  injuries  of  this  kind, 
ligature  of  the  carotid  artery,  which  has  been  frequently  practiced, 
usuall}''  serving  but  to  postpone  the  fatal  termination.  Owing  to  the 
liberal  supply  of  blood,  necrosis  seldom  occurs,  and  it  is  seldom  necessary 
to  remove  fragments  of  bone,  even  after  the  most  extensive  comminu- 
tion ;  they  should  be  left,  except  for  some  peculiar  reason,  until  death 
is  manifest  in  them,  when  they  may  be  abstracted  without  additional 
trouble.  Loosened  teeth  should  always  be  left  to  contract  adhesions, 
which  they  will  generally  readily  do.  Indeed,  but  little  surgical 
interference  is  required  in  cases  of  this  kind,  and  should  usually  be 
limited  to  efforts  to  secure  the  proper  apposition  of  the  teeth.  Numer- 
ous cases  of  the  most  extraordinary  injuries  to  the  face  are  to  be  found 
in  the  surgical  reports  of  thejate  war  in  the  States,  and  in  those  of  the 
French  and  English  surgeons  during  the  wars  of  the  first  Napoleon 
and  the  Crimea.  Fractures  of  the  superior  maxilla  may,  however, 
occur  from  other  violence  than  gunshot  wounds.  Mr.  Salter  reports  a 
case  resulting  from  the  collision  of  the  face  and  head  of  two  "  cricket- 
ers." The  kick  of  a  horse,  as  in  the  well-known  Wiseman  case,  has 
occasioned  frightful  injury  of  this  character.  In  this  case,  the  "  face 
was  driven  in,  the  lower  jaw  projecting  forward The  bones 

*  Cooper's  Surgical  Dictionary,  p.  306. 
38 


594  DENTAL   SURGERY. 

of  the  palate  were  driven  so  far  back,  it  was  impossible  to  pass  my 
finger  behind  them."  The  patient  made  a  good  recovery.  Mr.  Heath 
records  a  case  reported  by  Dr.  TyfFe,  in  which  "  on  watching  the 
patient's  profile  while  in  the  act  of  swallowing  food,  the  whole  of  the 
bones  of  the  face  were  observed  to  move  up  and  down  upon  the  fixed 
part  of  the  skull  as  the  different  parts  were  brought  into  motion.  It 
appeared  as  if  the  integuments  only  retained  them  in  their  position.  It 
was  a  curious  feature  in  the  case  that,  notwithstanding  the  very  exten- 
sive injury  done,  and  the  violent  character  of  the  force  which  caused 
it  (the  upsetting  of  a  cab),  not  a  single  tooth  was  fractured  or  mis- 
placed." Fractures  in  the  dentist's  chair,  from  ill-directed  efforts  to 
remove  teeth,  not  uncommon  when  "  keys"  were  in  general  use,  are 
now  so  infrequent  as  to  be  undeserving  of  special  mention. 

Among  the  complications  of  fracture  of  the  upper  jaw  may  be 
mentioned  breaking  and  displacement  of  teeth,  closure  of  the  nasal 
duct  with  cansequent  epiphora,  secondary  hemorrhage  and  paralysis 
of  the  infra-orbital  nerve,  as  the  most  common. 

Diagnosis  of  fractures  of  the  upper  jaw  is  usually  attended  with  but 
little  difficulty.  It  is  determined  by  pain,  crepitation,  irregularity  in 
the  line  of  the  teeth,  and  excessive  secretion  of  saliva.  The  treatment 
consists  in  the  nice  adaptation  of  the  teeth  and  their  permanent 
security  in  proper  position.  This  is  generally  effected  with  but  little 
difficulty,  by  a  single  finger  passed  into  the  mouth  to  press  the  frag- 
ments into  position,  where  they  may  be  secured  by  wires,  or,  in  cases 
of  great  displacement,  by  the  interdental  splint.  The  hemorrhage 
should  be  controlled  by  styptics,  of  which  the  persulphate  of  iron  is 
the  best,  by  the  actual  cautery,  and  when  not  otherwise  manageable, 
by  ligation  of  the  carotid  artery. 

Fractures  of  the  lower  jaw  are  much  more  common  than  those  of  the 
upper.  They  give  comparatively  little  trouble,  are  readily  diagnosed, 
and  are  occasioned  by  direct  violence,  as  in  the  upper  jaw.  The  most 
common  seat  of  fracture  is  the  middle  of  the  horizontal  ramus.  Before 
the  use  of  interdental  splints,  fractures  of  the  lower  jaw  were  difficult 
of  adjustment,  and  were  frequently  attended  with  bad  results,  and  in 
rare  cases  they  still  are  so.  A  good  many  forms  of  apparatus  have 
been  devised,  of  which  the  simplest  is  the  four-tailed  bandage,  which 
consists  of  a  slip  of  muslin,  of  suitable  dimensions,  torn  from  each  ex- 
tremity toward  the  centre,  leaving  enough  space  to  receive  the  chin. 
It  is  secured  by  passing  the  tails  over  the  top  of  the  head  and  around 
the  back  of  the  neck,  and  tying  them  in  this  position.  This  apparatus 
may  be  supplemented  by  a  pasteboard  splint  moulded  to  the  form  of 
the  jaw.  Sometimes  the  bones  are  secured  in  position  by  passing  wires 
around  the  firm  teeth  and  binding  them  together.     They  may  also  be 


DISLOCATION   AND   FRACTURE   OF  THE   JAW.  595 

secured  by  sutures,  the  bones  having  been  drilled  to  permit  their  pass- 
age. Mr.  Wheelhouse,  of  Leeds,  recommends  that,  after  drilling  through 
the  bones  on  either  side  of  the  fracture,  silver  pins  "  with  flat,  circular 
and  perforated  heads"  be  passed  through  the  opening  from  within  out- 
ward, and  their  points  bent  in  opposite  directions  so  as  to  form  hooks, 
and  the  fragments  secured  by  passing  silver  or  gold  wire  in  a  figure 
of  eight  over  the  pins.  The  perforations  in  the  head  of  the  wires  are 
for  silk  sutures,  by  which  they  may  be  readily  removed  when  necessary. 
It  is  also  recommended  that  not  only  should  the  fragments  be  secured 
together  in  this  way,  but  that  they  also  be  bound  to  the  upper  jaw. 
Wedges  of  cork  cut  into  suitable  shapes ;  of  gutta-percha,  introduced 
and  moulded  to  the  teeth ;  Mutter's  silver  clamps,  or  their  modification 
by  Mr.  Tomes ;  Hay  ward's  silver  caps,  and  other  more  complicated 
apparatuses  may,  in  our  judgment,  be  all  superseded  by  the  vulcanite 
interdental  splint  contrived  about 'the  same  time,  and  independently 
of  each  other,  by  the  late  Dr.  Bean,  of  Baltimore,  Md.,  and  Dr.  Gun- 
ning, of  New  York,  except  in  cases  of  obstinate  vertical  displacement. 
An  impression  in  wax  is  first  taken  of  both  jaws,  from  which  a  plaster 
cast  is  taken,  and  upon  this  the  vulcanite  plate  is  accurately  moulded 
with  indentations  corresponding  exactly  to  the  adjusted  teeth,  and 
with  an  interspace  at  the  most  convenient  point  for  administering  food. 
The  splints  are  now  introduced  into  the  mouth,  the  teeth  arranged  in' 
their  appropriate  indentations,  and  the  whole  fixed  in  position  by  a 
mental  compress  and  occipito-frontal  bandage,  thus  securing  the  jaws 
from  motion-  and  the  splint  from  displacement.  The  compress  consists 
of  a  light  piece  of  wood,  on  which  is  fixed  a  metallic  cup  of  form  and 
size  adapted  to  the  patient's  chin,  to  each  extremity  of  which  is 
affixed  a  metallic  side-piece  four  or  five  inches  in  length,  and  from 
three-quarters  to  one  inch  in  width.  Encasing  these  side-pieces  are  the 
temporal  straps  made  of  stout  cloth,  and  secured  by  a  strong  cord  at 
the  base  of  each  piece.  The  occipito-frontal  bandage  is  composed  of 
a  band  passing  around  the  head,  from  the  forehead  to  the  occipital 
protuberance  behind,  and  secured  by  a  buckle  one  inch  to  the  right 
of  the  median  line  behind ;  of  another  strap  secured  to  the  band  in 
front  and  behind ;  and  a  third  strap  extending  from  the  temporal 
buckles  on  either  side  and  secured  to  the  middle  strap  at  the  point  of 
crossing.     (See  Fig.  416.) 

An  "  impromptu  interdental  splint,"  the  suggestion  of  Professor 
Gorgas,  and  which  he  has  employed  with  great  satisfaction  in  hospital 
practice,  both  in  the  case  of  single  and  double  fractures  of  the  maxillae, 
is  described  as  follows  : — 

Taking  the  case  of  fracture  of  the  inferior  maxillary  for  example, 
after  all  the  parts  are  brought  in  apposition  and  secured  by  wire  or 


596 


DENTAL   SURGERY. 


silk  ligatures,  a  partial  lower  mouth  cup  or  tray,  of  the  proper  size  to 
suit  the  arch,  is  selected.     This  mouth  cup  is  of  the  form  having  an 


Fig.  416. 


opening  or  cavity  to  allow  the  front  teeth  under  other  circumstances 
to  pass  through,  and  is  represented  by  Fig.  417. 

Fig.  417. 


DISEASES   OF   THE    ANTRUM.  597 

The  partial  lower  cups  with  flat  bottoms  and  square  sides  are  more 
suitable  than  the  round-bottom  cups,  but  the  latter  may  be  used  with 
advantage  where  the  jaw  is  edentulous. 

"Wheu  the  fractured  portions  are  secured  in  position  by  ligatures, 
the  cup  is  filled  with  softened  modeling  composition  and  introduced 
into  the  mouth  in  the  same  manner  as  when  taking  an  impression  for 
a  partial  lower  set  of  teeth,  and  pressed  carefully  into  place.  The 
opening  or  cavity  in  the  front  part  of  the  cup  will  allow  the  modeling 
composition  to  press  through  to  the  upper  surface,  and  into  this  excess 
the  patient  is  directed  to  bite  with  the  superior  front  teeth,  and  the 
modeling  composition  is  adapted,  by  pressing  on  it  with  the  finger,  to 
the  labial  surfaces  of  these  teeth.  This  completes  the  formation  of  the 
interdental  splint,  which  the  patient  is  to  wear  until  union  of  the  frac- 
tured parts  takes  place.  The  handle  of  the  cup,  which  is  necessary  for 
its  introduction  into  the  mouth,  is  then  cut  off  close  to  the- cup  with  a 
fine  saw,  in  order  that  it  may  not  inconvenience  the  patient  by  pro- 
jecting beyond  the  lips.  The  openings  on  each  side  over  the  bicuspid 
and  molar  teeth  will  permit  the  introduction  of  nourishment,  without 
disturbing  the  appliance.  A  bandage  is  then  passed  over  the  top  of 
the  head  and  under  the  chin,  and  thus  an  easy  and  rapidly  formed 
"  interdental  splint "  is  improvised,  which  has  given  satisfaction  in 
every  case  where  it  has  been  applied,  and  permitted  of  removal  in 
from  three  to  four  weeks  from  the  time  it  was  applied.  Special  splints 
with  an  adjustable  handle,  which  may  be  removed  by  unscrewing  it, 
have  been  devised  by  Professor  Gorgas,  for  the  treatment  of  fractures 
of  both  jaws,  which  are  better  suited  to  the  jaws  than  the  ordinary 
mouth  cups  employed  for  obtaining  impressions  in  the  construction  of 
sets  of  artificial  teeth. 


CHAPTER  IX. 

DISEASES   OF    THE   A>^TRrM. 

THE  cavity  known  as  the  antrum  of  Highmore,  or  maxillary  sinus, 
is  situated  in  the  body  of  the  superior  maxillary  bone,  on  either 
side  of  the  nose  and  beneath  the  orbit  of  the  eye.  It  is  an  irregular 
cavity,  varying  in  size  in  nearly  every  superior  maxillary  bone,  and 
often  divided  into  several  parts  by  vertical  partitions  (septi)  of  bone  ; 
an  observation  of  many  bones  being  necessary  to  show  its  extent  and 
general  form.  The  alveolar  process  immediately  over  the  ends  of  the 
roots  of  the  first  and  second  superior  molars  and  bicuspids,  forms  the 


598  DENTAL   SURGERY. 

floor  of  the  antrum  ;  hence  it  is  readily  seen  how  abscesses  of  the  roots 
of  these  teeth  may  involve  this  cavity. 

One  of  the  nasal  openings  of  the  antrum,  of  which  there  are  two 
into  the  middle  meatus  of  the  nose,  when  in  a  normal  condition,  is 
very  nearly  closed  by  a  duplicature  of  the  membrane  lining  the  turbi- 
nated and  other  adjoining  bones,  and  secretions  may  readily  accumulate 
when  this  outlet  into  the  nose  is  closed  by  congestion  of  the  membrane, 
giving  rise  to  serious  symptoms,  such  as  disfigurement,  pain,  etc.  The 
other  opening  is  very  small,  and  can  only  be  entered  with  the  point  of 
a  probe.  The  mucous  membrane  which  lines  the  nares  passes  through 
these  openings  into  the  antrum,  and  lines  this  cavity  also. 

The  antrum  is  subject  to  some  of  the  most  formidable  and  dangerous 
diseases  the  medical  or  surgical  practitioner  is  ever  called  upon  to  treat; 
and  yet  there  are  few  diseases  incident  to  the  human  body  that  have 
received  less  attention  from  writers  on  pathology  and  therapeutics  than 
these.  There  are  diseases  here  met  with  over  which  neither  the  sur- 
geon nor  physician  can  exercise  any  control,  the  progress  of  which 
ceases  only  with  the  life  of  the  unfortunate  sufferer. 

All  of  the  diseases  to  which  the  maxillary  antrum  is  subject,  however, 
are  not  of  so  dangerous  a  character,  for  some  are  very  simple  and  easily 
cured  ;  but  even  those  which  are  regarded  as  the  least  dangerous,  and 
which  yield  most  readily  to  treatment,  when  instituted  during  their 
incipient  or  earlier  stages,  may  assume,  if  neglected,  or  improperly 
treated,  a  form  so  aggravated  as  to  bid  defiance  to  the  skill  both  of  the 
physician  and  surgeon,  ,'^'^^^ile  thus,  on  the  one  hand,  the  most  simple 
affections  of  this  cavity 'taaW  by  neglect  or  improper  treatment,  become 
ultimately  incurable,  many  of  those,  on  the  other  hand,  which  are 
considered  the  most  malignant  and  dangerous,  might,  we  have  no 
doubt,  by  timely  and  judicious  treatment,  be  effectually  and  radically 
removed. 

The  form  which  the  disease  puts  on  is  determined  by  the  state  of  the 
constitutional  health  or  some  specific  tendency  of  the  general  system ; 
and  we  can  readily  imagine  that  a  cause  which,  in  one  person,  would 
give  rise  to  simple  inflammation  of  the  lining  membrane,  or  mucous 
engorgement  of  the  sinus,  would,  in  another,  produce  an  ill-conditioned 
ulcer,  fungus  heematodes,  or  osteo-sarcoma.  Simple  inflammation  and 
mucous  engorgement  not  unfrequently  cause  caries  and  exfoliation  of 
the  surrounding  osseous  tissues,  and,  in  some  instances,  even  the  de- 
struction of  the  life  of  the  patient. 

The  importance  of  early  attention  to  the  diseases  of  this  cavity  is, 
therefore,  very  apparent;  and  this  is  the  more  necessary  as  it  is  often 
difficult,  and  sometimes  impossible,  to  determine  the  character  of  the 
malady  until  it  has  progressed  so  far  as  to  involve,  to  a  greater  or  less 


DISEASES   OF   THE   ANTRUM.  599 

extent,  the  neighboring  parts,  when,  if  it  has  not  become  incurable, 
its  removal  is,  to  say  the  least,  rendered  less  easy  of  acconiplishnient. 
It  may  be  safely  assumed,  therefore,  that  in  a  very  large  majority  of 
the  cases  of  disease  of  the  maxillary  sinus,  the  danger  to  be  apprehended 
arises  more  from  neglect  than  from  any  necessarily  fatal  character  of 
the  malady,  so  that,  in  forming  a  prognosis,  the  circumstances  to  be 
considered  are  the  state  of  the  constitutional  health,  the  progress  made 
by  the  affection,  and  the  nature  of  the  injury  inflicted  by  it  upon  the 
surrounding  tissues.  If  the  general  health  is  not  so  much  impaired  as 
to  prevent  its  restoration  by  the  employment  of  proper  remedies,  and 
the  neighboring  structures  have  not  become  implicated,  the  prognosis 
will  be  favorable ;  but  if  the  functional  operations  of  the  body  have 
become  very  much  deranged,  and  the  bones  of  the  face  and  nose 
seriously  affected,  the  combined  resources  both  of  medicine  and  surgery 
will  prove  unavailing. 

In  young  and  middle-aged  subjects  of  good  constitution,  a  morbid 
action  may  exist  in  the  antrum  for  years,  without  giving  rise  to  anv 
alarming  symptoms,  while  the  same  affection  in  another  less  healthy 
might  rapidly  extend  and  degenerate  into  a  form  of  disease  so  malig- 
nant as  to  threaten  the  speedy  destruction  of  the  life  of  the  patient. 
Medical  history  abounds  with  examples  of  this  kind,  and  conclusively 
establishes  the  fact  that  the  state  of  the  general  health  and  habit  of 
body,  whatever  may  have  been  the  primitive  characteristics  of  the 
malady,  ultimately  determines  its  malignancy;  in  the  treatment  of 
affections  of  this  cavity,  therefore,  as  well  as  of  other  local  diseases  of 
the  body,  the  condition  of  the  system  should  not  be  overlooked. 

Independently  of  the  danger  arising  from  the  local  affection,  diseases 
of  the  antrum  are,  for  the  most  part,  very  loathsome,  and  subject  the 
patient  to  great  annoyance.  They  change  the  quality  of  its  secretions, 
and  cause  them  to  exhale  a  fetid,  nauseating  odor.  This,  in  many 
instances,  is  almost  insufferable  to  the  patient,  and  when  they  are  pre- 
vented from  escaping  through  the  natural  opening  into  the  nose,  they 
pass  through  one  artificially  formed  by  the  surgeon,  or  made  by  the 
disease  through  the  cheek,  alveolar  border  or  palatine  arch,  always 
causing  the  patient  great  inconvenience. 

The  progress  of  disease  in  this  cavity  is  often  very  insidious.  It  not 
unfrequently  happens  that  it  exists  for  weeks  and  even  months  before 
its  existence  is  suspected.  The  slight  uneasiness  felt  is  attributed  to 
some  morbid  condition  of  the  teeth  or  gums,  and  the  symptoms  attend- 
ant upon  one  description  of  affection  are  often  so  similar  to  those  that 
accompany  another,  that  it  is  impossible  to  determine  its  true  character 
until  it  has  made  considerable  progress. 

The  morbid  affections  of  the  maxillary  sinus  are,  for  the  most  part, 


600  DENTAL  SURGERY. 

similar  to  those  of  the  nasal  fossse.  There  is,  however,  one  form  of 
disease  which  seems  to  be  peculiar  to  this  cavity,  viz.,  mucous  engorge- 
ment. Deschamps  mentions  two  kinds  of  accumulations,  drojjsical 
and  purulent;  but  the  first  of  these  is,  properly  speaking,  a  disease  of 
serous  membranes,  and  is  never  met  with  in  this  cavity ;  and  authors, 
who  have  enumerated  it  among  its  diseases,  have  evidently  mistaken 
mucous  engorgement  for  it.  The  fluids  that  accumulate  here  are  of  a 
mucous  or  muco-purulent  character,  except  when  they  are  the  result 
of  the  disorganization  of  some  of  the  surrounding  parts ;  then  they 
are  sanious. 

The  most  simple  form  of  disease  that  occurs  here  is  inflammation  of 
the  lining  membrane,  and  this,  in  most  instances,  may  be  said  to  pre- 
cede all  others.  It  often  subsides  spontaneously ;  but,  when  it  con- . 
tinues  for  a  long  time,  is  apt  to  become  chronic,  and  may  then  give  rise 
to  other  and  more  formidable  kinds  of  disease.  When  unattended  by 
any  other  morbid  affection,  either  local  or  constitutional,  it  is  easily 
cured. 

A  purulent  condition  of  the  fluids  of  the  antrum  is  a  common  affec- 
tion, but  is  seldom  met  with  in  persons  of  good  constitution.  It  seems 
to  be  dependent  upon  a  bad  habit  of  body ;  also  upon  inflammation  of 
the  mucous  membrane  of  the  sinus,  which  arises  more  frequently  from 
dental  irritation  than  any  other  cause.  This  condition  of  the  secretions 
sometimes  gives  rise  to  caries  and  exfoliation  of  portions  of  the  sur- 
rounding bone,  and  to  fistulous  ulcers;  but  when  dependent  upon  no 
other  local  cause  than  simple  inflammation  of  the  mucous  membrane, 
it  is  seldom  that  such  effects  result  from  it.  When  complicated  with 
other  morbid  conditions  of  the  cavity,  they  are  not  unfrequent. 

All  purulent  secretions  of  this  membrane  are  by  some  denominated 
abscess.  The  name,  however,  as  is  justly  remarked  by  Mr.  Thomas 
Bell,  is  improper.  The  term  abscess  is  more  correctly  applied  to  puru- 
lent collections  in  the  areolar  tissue — either  submucous,  subserous, 
subcutaneous,  intermuscular,  or  parenchymatous.  It  seldom  originates 
in  the  submucous  tissue  of  the  antrum,  but  proceeds  occasionally  from 
disease  in  the  cancellated  structure  of  the  surrounding  bones.  Instances 
of  it  have  been  met  with  at  the  extremities  of  the  roots  of  teeth  which 
had  perforated  the  sinus ;  and  it  sometimes  happens  that  when  an  ab- 
scess is  seated  in  the  alveolus  of  a  superior  molar,  the  matter,  instead 
of  making  for  itself  a  passage  through  the  socket  of  the  tooth  on  either 
side,  escapes  into  this  cavity,  and  thence  with  the  antral  secretions 
through  the  nasal  opening.  Mr.  Bell  describes  a  case  of  abscess  seated 
in  the  upper  part  of  the  antrum ;  but  this,  and  one  other,  are  the  only 
examples  of  this  kind  on  record. 

Ulceration  of  the  lining  membrane  is  an  affection  less  frequently 


DISEASES   OF   THE   ANTRUM.  601 

met  with.  It  is  rarely,  if  ever,  idiopathic,  but  seems  rather  to  be  de- 
pendent upon  some  other  local  malady  or  some  specific  constitutional 
vice.  Scorbutic  and  scrofulous  diatheses,  and  those  affected  with  a 
venereal  taint,  are  more  liable  to  ulceration  of  this  membrane  than 
persons  of  sound  constitution.  Consequently,  it  is  seldom  cured  by 
local  remedies  alone.  It  is  almost  always  complicated  with  fungus 
of  the  membrane  and  caries  of  the  walls  of  the  sinus,  and  may,  if 
neglected,  take  on  a  cancerous  form  and  become  incurable. 

The  next  form  of  disease  is  caries  of  the  antral  parietes.  This, 
though  always  complicated  with  other  forms  of  diseased  action,  seems, 
nevertheless,  to  be  worthy  of  separate  consideration.  Like  ulceration 
of  the  lining  membrane,  it  is  the  result  of  some  other  affection.  It 
may  result  from  accumulation  of  the  secretions  of  the  sinus,  from 
ulceration,  or  from  tumors. 

The  occurrence  of  fungus  or  polypus  and  of  various  kinds  of  tumor 
is  less  frequent  than  any  of  the  preceding  affections ;  yet  this  cavity  is 
not  exempt  from  them,  and  they  constitute  the  most  dangerous  form 
of  disease  to  which  the  superior  maxilla  is  subject.  Although  it  is 
probable  that,  in  their  incipient  stage,  they  might  in  nearly  every  in- 
stance be  radically  removed,  it  is  seldom  they  are  cured  after  they 
have  attained  a  very  large  size,  and  have  implicated,  to  considerable 
extent,  the  surrounding  tissues.  They  have,  however,  been  successfully 
extirpated  even  after  they  had  acquired  great  volume,  and  implicated 
to  such  an  extent  the  surrounding  parts  as  to  render  necessary  the 
removal  of  the  whole  of  the  superior  maxillary  bone.  They  usually 
grow  with'  great  rapidity,  and,  if  not  completely  removed,  are  soon 
reproduced. 

Besides  these,  other  varieties  of  disease  are  occasionally  met  with 
here.  The  antrum  is  liable  to  injuries  from  blows  and  other  kinds  of 
mechanical  violence,  and  from  the  introduction  of  insects  and  foreign 
bodies.  The  diseases  of  the  maxillary  sinus  are  supposed  to  be  de- 
pendent upon  certain  specific  constitutional  vices;  upon  the  obliteration 
of  the  opening  of  this  cavity  into  the  nose,  and  upon  dental  irritation. 
That  all  of  these  may,  at  times,  be  concerned  in  their  production,  is 
more  than  probable.  But  actual  disease  rarely  develops  itself  sponta- 
neously as  a  consequence  merely  of  a  bad  habit  of  body  or  constitu- 
tional vice.  This  does  not  of  itself  originate  disease,  but  only  occasions 
an  increase  of  susceptibility  of  the  tissues  to  morbid  impressibns ;  so  that 
when  an  unhealthy  action  is  once  induced  here,  a  more  aggravated  or 
a  different  form  of  disease  occurs  than  that  which  would  otherwise  have 
been  produced. 

Thus  it  may  be  seen  that  disease  of  the  maxillary  sinus  is  dependent 
upon  some  exciting  cause,  favored  by  some  constitutional  vice;  for 


602  DENTAL   SURGERY. 

without  this  no  serious  morbid  effects  would  be  produced,  or,  if  pro- 
duced, they  would  be  of  a  different  and  less  aggravated  character. 
Any  disposition  or  vice  of  body  which  weakens  the  vital  energies  of 
the  system,  increases  the  susceptibility,  or  rather  excitability,  of  all  its 
parts — those  of  this  cavity  equally  with  the  rest.  There  are  various 
kinds  which  have  this  effect ;  as, -for  example,  the  scorbutic,  scrofulous, 
venereal,  mercurial,  etc.,  each  of  which  may  influence  the  character 
of  the  morbid  action  in  a  manner  peculiar  to  itself;  or  it  may  be 
similar  to  that  which  might  be  exercised  by  another,  only  causing  it 
to  assume  a  greater  or  less  degree  of  malignancy,  accordingly  as  the 
functional  operations  of  the  body  generally  are  more  or  less  enervated 
by  it. 

This  seems  to  be  the  way  in  which  a  bad  habit  of  body  is  capable  of 
affecting  the  maxillary  sinus.  It  is  a  predisposing,  but  not  an  exciting 
■  cause  of  disease;  and  it  is  important  that  this  distinction  should  be 
borne  in  mind.  The  one  should  never  be  confounded  with  the  other, 
because  an  error  of  this  sort  might,  in  many  instances,  lead  to  the  adop- 
tion of  incorrect  views  concerning  the  therapeutical  indications  of  the 
disease.  This  part  of  the  subject  we  shall  have  occasion  to  advert  to 
hereafter. 

Inflammation  and  ulceration  of  the  nasal  pituitary  membrane  some- 
times extend  themselves  to  the  maxillary  sinus ;  but  disease  is  not  so 
frequently  propagated  from  the  nasal  fossae  to  this  cavity  as  the  inti- 
mate relationship  between  the  two  might  lead  one  to  suppose.  It  is 
seldom  that  both  are  affected  at  the  same  time.  Hence  we  infer,  that, 
although  lined  by  one  common  membrane,  the  propagation  of  disease 
from  one  to  the  other  is  a  rare  occurrence. 

The  obliteration  of  the  nasal  opening  of  this  cavity  is  sometimes 
caused  by  disease  in  the  nose,  and  is  followed  by  mucous  engorgement 
of  the  sinus,  inflammation  of  the  lining  membrane,  distention  of  the 
osseous  walls,  and  not  unfrequently  by  other  and  more  complicated 
forms  of  disease.  But  the  closing  of  this  opening  is  oftener  an  effect 
than  a  cause  of  disease  in  this  cavity,  and  it  generally  re-establishes 
itself  without  any  assistance  of  art  after  the  cure  of  the  affection  which 
caused  it. 

If  all  the  circumstances  connected  with  the  history  of  the  diseases 
under  consideration  could  be  ascertained,  we  think  it  would  be  found 
that  these  affections  are  more  frequently  induced  by  a  morbid  condition 
of  the  teeth,  gums  and  alveolar  processes  than  any  other  cause.  There 
are,  in  fact,  no  sources  of  irritation  to  which  this  cavity  is  so  much  and 
so  often  exposed  as  those  arising  from  the  dental  organism.  It  is  sepa- 
rated from  the  apices  of  the  roots  of  the  superior  molars  and  bicuspids 
by  only  a  very  thin  plate  of  bone,  and  is  sometimes  even  penetrated 


DISEASES   OF   THE   ANTRUM.  G03 

by  them;  so  that  it  could  scarcely  be  otherwise  than  that'  aggravated 
and  protracted  disease  in  the  teeth  and  alveoli  should  exert  an  un- 
healthy influence  upon  it.  The  pain  occasioned  by  diseased  teeth  is 
often  very  severe,  sometimes  almost  excruciating,  and  inflammation  in 
the  alveoli-dental  periosteum  and  gums  frequently  extends  itself  to  the 
whole  of  one  side  of  the  face.  It  could  hardly  be  possible,  therefore, 
for  this  cavity  to*  escape.  Alveolar  abscess,  and  sometimes  necrosis 
and  exfoliation  of  the  socket  of  the  affected  tooth,  arise  from  the  inflam- 
mation thus  lighted  up.  It  often  happens  that  the  gums  and  alveolar 
periosteum  are  affected  for  years  with  chronic  inflammation  and  other 
morbid  affections. 

If,  in  addition  to  these  facts,  other  proofs  be  necessary  to  establish 
the  agency  of  dental  and  alveolar  irritation  in  the  production  of  disease 
in  the  maxillary  sinus,  they  may  be  fonnd.  Many  of  the  affections 
here  met  with  are  often  cured  by  the  removal  of  diseased  teeth  after 
other  remedies  have  been  employed  in  vain,  and  that  without  even 
perforating  the  antrum.  This  would  not  be  the  case  if  the  irritation 
did  not  arise  as  a  consequence  of  the  dental  malady. 

Most  writers  on  diseases  of  the  sinus  agree  in  ascribing  them  to  a 
morbid  condition  of  the  teeth  and  alveoli.  There  are  some,  however, 
who,  though  they  admit  that  dental  irritation  may,  perhaps,  occasionally 
give  rise  to  them,  seem,  nevertheless,  to  attribute  their  occurrence,  in 
the  majority  of  instances,  to  other  causes,  such  as  irregular  exposure  to 
cold,  blows  upon  the  face,  and  certain  constitutional  diseases.  We  shall 
now  proceed  to  the  consideration  of  some  of  the  more  common  affections 
of  this  cavity,  under  their  respective  and  appropriate  heads. 

Inflammation  of  the  Lining  Membrane  of  the  Maxillary  Sinus. — Inflam- 
mation, when  not  complicated  with  any  other  morbid  affection,  is  the 
most  simple  form  of  disease  to  which  the  pituitary  membrane  of  the 
antrum  is  subject.  As  it  precedes  and  accompanies  all  others,  it  will 
be  proper  to  offer  a  few  remarks  upon  it  before  entering  upon  the 
consideration  of  those  of  a  more  aggravated  nature. 

Inaccessible  as  it  is  here  to  most  of  the  acrid  and  irritating  agents' 
to  which  it  is  exposed  in  the  nasal  fossse  and  some  other  cavities  of  the 
body,  it  would  rarely  become  the  seat  of  inflammation,  were  it  not  for 
its  proximity  to  the  teeth  and  alveolar  border ;  and  simple  inflammation- 
rarely  gives  rise  to  any  other  form  of  diseased  action,  unless  favored 
by  some  general  morbid  tendency,  but  usually  subsides  spontaneously 
on  the  removal  of  the  exciting  cause.  In  good  constitutions  it  is  less 
subject  to  inflammation,  and,  consequently,  to  any  other  description  of 
morbid  action,  than  those  in  whom  there  exists  some  vice  of  body  or 
constitutional  predisposition.  Febrile  and  gastric  affections ;  eruptive 
diseases,  such  as  measles,  smallpox,  etc. ;  syphilis,  and  excessive  and 


604  DENTAL   SURGERY. 

protracted  use  of  mercurial  medicines;  a  scorbutic  or  scrofulous  dia- 
thesis of  the  general  system — in  short,  everything  that  has  a  tendency 
to  enervate  the  vital  powers  of  the  body,  increases  its  irritability. 

"When  in  a  healthy  condition,  it  secretes  a  slightly  viscid,  transparent 
and  inodorous  fluid,  by  which  it  is  constantly  lubricated  ;  but  inflam- 
mation changes  the  character  of  the  secretion.  It  causes  it  to  become 
vitiated  ;  at  first  less  abundant,  it  is  afterward  secreted  in  larger  quan- 
tities than  usual,  becomes  more  serous,  and  so  acrid  as  sometimes  to 
irritate  the  membrane  of  the  nose,  over  which  it  passes  after  having 
escaped  from  the  antrum.  It  also  exhales  an  odor  more  or  less  ofien- 
sive,  accordingly  as  the  inflammation  is  mild  or  severe.  It  moreover 
gives  rise  to  a  thickening  of  the  membrane,  and  sometimes  to  oblitera- 
tion of  the  nasal  opening.  This  last  rarely  occurs ;  but  when  it  does 
happen,  an  accumulation  of  the  secretion  and  other  morbid  phenomena, 
of  which  we  shall  hereafter  treat,  result  as  a  necessary  consequence. 

If  at  any  time  during  the  continuance  of  the  inflammation,  the  patient 
is  attacked  with  severe  constitutional  disease,  the  local  affection  will 
be  aggravated,  and  sometimes  assume  a  different  character. 

The  inflammation,  when  long  continued,  degenerates  into  a  chronic 
form,  and  is  sometimes  kept  up  for  several  years,  without  giving  rise 
to  any  other  unpleasant  symptoms  than  occasional  paroxysms  of  dull 
and  seemingly  deep-seated  pain  in  the  face,  and  a  vitiated  condition 
of  the  fluids  of  this  cavity.  The  slightly  fetid  odor  which  they  exhale 
ceases  to  be  annoying  or  even  perceptible  to  the  patient,  when  he 
becomes  accustomed  to  it. 

Symptoms. — The  symptoms  of  inflammation  here,  though  not  always 
precisely  the  same  as  elsewhere,  are,  for  the  most  part,  very  simi- 
lar. They  are  severe,  fixed  and  deep-seated  pain  under  the  cheek, 
extending  from  the  alveolar  border  to  the  lower  part  of  the  orbit; 
local  heat,  pulsation,  and  sometimes  fever.  Boyer  says  these  symp- 
toms are  not  always  present,  and  that  inflammation  may  exist 
when  it  is  not  suspected.  Other  affections  of  the  face  and  superior 
maxilla  may  be  mistaken  for  this,  and  this  for  others ;  but  that  inflam- 
mation should  exist,  without  being  attended  with  pain  or  any  other 
signs  indicative  of  its  presence,  is  scarcely  probable. 

Deschamps  distinguishes  the  symptoms  of  this  from  those  of  other 
affections  of  this  cavity  by  a  dull,  heavy  pain  in  the  region  of  the 
sinus,  which,  he  says,  becomes  sharp  and  lancinating,  and  extends 
from  the  alveolar  arch  to  the  frontal  sinus.  The  disease  goes  on 
without  interruption,  increasing  until  the  superior  maxilla  of  the 
affected  side  is  more  or  less  involved.  This  malady,  he  says,  cannot  be 
confounded  with  any  othex',  even  where  there  is  no  external  visible 
cause  ;  differing  from  a  simple  retention  of  mucus,  by  being  painful  at 


DISEASES   OF   THE   ANTEUlSf.  605 

the  commencement,  and  by  not  being  accompanied  with  swelling  of  the 
bones ;  from  polypus,  by  the  continuance  of  pain ;  and  from  cancer, 
by  the  character  of  the  pain.  "  Suppuration  and  ulcers  have  peculiar 
signs  which  cannot  be  confounded  with  those  of  inflammation."  Pain 
in  the  molar  and  bicuspid  teeth,  accompanied  by  a  sense  of  fluctuation 
in  the  parts,  he  seems  to  regard  as  a  very  certain  indication  of  inflam- 
mation, and  especially  when  joined  to  the  other  symptoms.  "  If  an 
external  cause  is  discovered,  it  will  furnish  a  certain  diagnosis :"  he 
also  mentions  fever  and  headache  as  almost  invariable  accompani- 
ments. 

The  inflammation,  if  not  subdued  by  appropriate  remedies,  after 
having  continued  for  a  length  of  time,  gradually  assumes  a  chronic 
form  ;  the  pain  then  begins  to  diminish,  and  is  less  constant ;  it  becomes 
duller,  and  is  principally  confined  to  the  region  of  the  antrum.  The 
teeth  of  the  affected  side  cease  to  ache,  or  ache  only  at  times,  but  still 
remain  sensitive  to  the  touch.  The  mucous  membrane  of  the  nostril 
next  the  diseased  sinus  is  often  tender  and  slightly  inflamed ;  and  if 
in  the  morning,  or  after  two  or  three  hours'  sleep,  the  other  nostril  be 
closed  by  pressing  upon  it  with  the  thumb  or  one  of  the  fingers,  and  a 
violent  expiration  be  made,  a  thin  watery  fluid,  of  a  slightly  fetid  odor, 
will  be  discharged,  and  pain  will  be  experienced  in  the  region  of  this 
cavity. 

Causes. — All  morbid  conditions  of  the  teeth  and  gums,  causing  irri- 
tation in  the  alveolar  periosteal  tissue,  may  be  regarded  as  among  the 
most  frequent  of  its  exciting  causes,  especially  caries,  necrosis,  and 
exostosis ;  also,  loose  teeth,  and  the  roots  of  such  as  have  been  either 
fractured  in  an  attempt  at  extraction,  or  by  a  blow  or  fall,  and  left  in 
their  sockets,  or  that  have  remained  after  the  destruction  of  their  crowns 
by  decay.  It  sometimes  happens,  too,  that  inflammation  is  excited  in 
this  membrane  by  fractured  alveoli ;  but  when  an  accident  of  this  sort 
occurs,  the  detached  portions  of  bone  are  generally  soon  thrown  off*  by 
the  economy,  and  the  cause  being  removed,  the  inflammation  immedi- 
ately subsides.  Not  so  with  the  roots  of  the  teeth.  They  often  remain 
concealed  in  their  sockets  for  years,  unless  removed  by  art.  Nature, 
it  is  true,  makes  an  effort  to  expel  them  from  the  jaw,  but  this  is  ac- 
complished only  by  a  slow  and  very  tedious  process,  and  not,  in  many 
instances,  until  they  have  given  rise  to  some  serious  affection.  But  of 
the  deleterious  effects  that  result  from  necrosed  roots  of  teeth  in  the 
alveoli,  it  is  not  necessary  now  to  speak ;  as  extraneous  bodies,  they 
are  always  productive  of  more  or  less  irritation.  We  might  also 
mention  exposure  to  sudden  transitions  of  temperature,  and  certain 
constitutional  diseases,  as  among  the  causes  which  occasionally  give 
rise  to  inflammation  of  this  membrane. 


606  DENTAL  SURGERY. 

Treatment. — The  curative  indications  of  inflammation  of  the  lining 
membrane  of  the  antrum  are  simple,  and,  for  the  most  part,  similar 
to  those  of  inflammation  in  other  parts  of  the  body.  In  many  cases, 
great  benefit  will  be  derived  from  the  application  of  leeches  to  the 
cheek,  as  recommended  by  Mr.  Thomas  Bell.  When  the  disease  is 
dependent,  as  in  most  cases  it  is,  upon  an  unhealthy  condition  of  the 
alveolar  processes,  the  first  thing  to  be  done  is  to  remove  all  such  teeth, 
or  roots  of  teeth,  as  are  productive  of  the  least  irritation  ;  for  while 
any  local  sources  of  irritation  are  permitted  to  remain,  neither  topical 
nor  general  oleeding,  or  indeed  any  other  treatment,  will  be  of  per- 
manent advantage. 

Simple  inflammation  of  the  lining  membrane  of  the  antrum  would 
be  of  little  consequence,  were  it  not  that  it  is  liable  to  give  rise  to  other 
and  more  dangerous  forms  of  disease,  such,  for  instance,  as  engorgement 
or  a  purulent  condition  of  its  secretions.  It  should  never,  therefore, 
be  permitted  to  continue,  but  be  as  speedily  arrested  as  possible ;  and 
for  the  accomplishment  of  this,  the  means  here  pointed  out  will,  if 
timely  and  properly  applied,  be  found  fully  adequate. 

Purulent  Condition  of  the  Secretions  and  Engorgement  of  the  An- 
trum.— A  purulent  condition  of  the  secretions  of  the  antrum  and 
mucous  engorgement  are,  indiscriminately,  though  very  improperly, 
denominated,  by  many  writers  on  the  affections  of  this  cavity,  abscess. 
To  this,  neither  bears  the  slightest  resemblance.  Deschamps  treats  of 
the  former  under  the  name  of  suppuration,  and  the  latter,  dropsy.  Of 
the  first,  he  says,  "  If,  by  the  time  the  inflammation  has  passed,  the 
surrounding  parts  cease  to  be  painful,  while  the  affection  still  continues 
to  cause  pain  in  the  antrum,  and  the  fever,  though  diminished,  occurs 
at  irregular  intervals,  and  if  the  inflammation  is  followed  by  pulsating 
pain,  we  have  reason  to  suppose  that  an  abscess  has  formed  in  the  sinus ; 
and  all  doubt  will  be  removed,  if,  on  the  patient's  inclining  his  head 
to  the  opposite  side,  matter  is  discharged  into  the  nostrils,  or  if  some 
tubercles  are  formed  near  the  outer  angle  of  the  eye,  or  alveolar  border, 
which  last  happens  more  frequently  ;  and  finally,  if  the  purulent  matter, 
not  finding  any  opening  through  which  to  discharge  itself,  distends  the 
sinus  to  such  an  extent  as  to  form  a  tumor  outwardly  upon  the  cheek." 
In  short,  all  the  symptoms  which  he  mentions  as  belonging  to  the 
disease  are  those  accompanying  the  one  under  consideration.  The 
matter,  he  says,  is  of  a  "  putrid,  serous  consistence." 

Bordenave  has  fallen  into  a  similar  error.  He  terms  an  altered 
state  of  these  secretions  suppuration  of  the  membrane,  and  says  that 
inflammation  is  not  necessary  to  it.  He  seems  to  have  confounded 
with  abscess  of  the  antrum  those  cases  of  alveolar  abscess  where  the 
matter,  instead  of  discharging  itself,  as  it  ordinarily  does,  by  an  open- 


DISEASES   OF   THE   ANTRUM.  607 

ing  through  the  alveolus  and  gum  into  the  mouth,  passes  into  that 
cavity.  Again  he  asserts  that  the  disease  (suppuration,  as  he  calls  it) 
may  be  independent  or  the  surrounding  parts;  and  although  ordinarily 
implicated  with  an  altered  condition  of  them,  he  affirms,  it  is  some- 
times the  effect  of  disease  primarily  seated  in  the  cavity. 

There  is  no  doubt  that  a  purulent  condition  of  the  fluids  of  this  cavity 
is  often  complicated  with  ulceration  of  the  lining  membrane;  but  that 
the  affection  is  different  from  abscess,  its  very  nature  and  situation  are 
sufficient  to  show.  "A  reference  to  the  structure  of  the  antrum,"  says 
Mr.  Bell,  "would  appear  to  be  sufficient  to  point  out  the  improbability, 
to  say  the  least,  of  the  occurrence  of  abscess  in  such  a  situation.  That 
a  mucous  membrane  covering,  in  a  thin  layer,  the  whole  internal  sur- 
face of  such  a  cavity,  should  become  the  seat  of  all  the  consecutive 
steps  of  true  abscess,  is  a  statement  bearing  on  the  face  of  it  an  obvious 
absurdity."  Notwithstanding  the  seeming  improbability  of  such  an 
occurrence — and  it  is  certainly  one  that  very  rarely  happens — abscess 
does  sometimes  develop  itself  in  this  cavity ;  but  it  is  a  different  affec- 
tion altogether  from  that  usually  treated  of  under  that  name. 

When  complicated  with  ulceration  of  the  mucous  membrane — and 
it  is  probable  that  a  purulent  condition  of  its  secretions,  in  most 
instances,  is  thus  complicated — the  affection  is  analogous  to  ozsena,  and 
many  of  the  older  writers  designate  it  by  that  name.  Mr.  Bell  describes 
it,  and  very  properly  too,  as  being  similar  to  gonorrhoea  ;  both  diseases 
alike  consist  in  an  alteration  of  secretion ;  in  the  one  case  of  the  pitui- 
tary membrane,  and  in  the  other  of  the  mucous  lining  of  the  urethra; 
but  in  neither  instance  does  it  possess  any  of  the  characteristics  of 
abscess,  though  the  matter  in  both  is  purulent. 

It  has  been  before  stated  that  the  obliteration  of  the  nasal  opening 
was  more  frequently  an  effect  than  a  cause  of  disease  in  the  maxillary 
sinus ;  it  does,  however,  sometimes  become  closed  from  other  causes 
than  an  unhealthy  condition  of  this  cavity ;  when  this  happens,  en- 
gorgement of  the  sinus  is  the  inevitable  consequence.  The  fluids  thus 
accumulated  are  not  always  at  first  purulent,  although  they  may  sub- 
sequently become  so  ;  when  the  closing  of  the  opening  is  the  result  of 
previous  disease  in  the  antrum,  the  secretions  are  more  or  less  altered 
from  the  very  first. 

Accumulation  of  any  secretion  within  the  antrum,  whether  of  mucus 
or  pus,  is  a  source  of  irritation  to  the  lining  membrane,  and  the  pressure 
which  it  ultimately  exerts  upon  the  surrounding  walls  causes  a  new 
form  of  diseased  action,  which  not  unfrequently  involves  in  disease 
all  the  bones  of  the  face  as  well  as  those  of  the  base  of  the  cranium. 
When  prevented  from  escaping  through  the  nasal  opening,  the  secre- 
tion eventually  makes  for  itself  a  way  of  escape — sometimes  through 


608  DENTAL   SURGERY. 

the  cheek;  at  other  times  beneath  it,  just  above  the  alveolar  ridge;  or 
through  the  palatine  arch  or  alveoli  by  the  sides  of  the  roots  of  one  or 
more  of  the  teeth ;  and  from  a  fistula  thus  established  fetid  matter  will 
be  almost  constantly  discharged.  From  openings  of  this  sort  the 
matter  is  sometimes  discharged  for  years,  while  the  disease  in  the 
antrum,  very  frequently,  does  not  seem  to  undergo  any  apparent  change. 
At  other  times  the  membrane  ulcerates  and  the  bony  walls  become 
carious. 

A  purulent  secretion  from  the  mucous  membrane  of  this  cavity,  inde- 
pendently of  caries  of  the  bone,  or  even  of  simple  fistulous  openings, 
is  an  exceedingly  troublesome  and  unpleasant  affection.  The  odor 
from  the  matter  is  often  very  annoying,  even  to  the  patient,  and  when 
the  secretions  are  retained  for  some  days  in  the  sinus  before  they  escape, 
the  fetor  is  almost  insufferable. 

In  good  constitutions  the  secretions  of  the  antrum  are  not  so  liable 
to  become  purulent,  though  they  be  confined  for  a  long  time  in  the 
cavity,  and  thus  become  more  or  less  offensive.  Inflammation  of  the 
lining  membrane  (the  immediate  or  proximate  cause)  may  exist  for 
years  without  giving  rise  to  it.  It  is  only  in  scrofulous,  scorbutic  or 
debilitated  habits  that  they  are  liable  to  become  thus  altered.  The 
difference  in  the  eflfects  produced  upon  them  and  the  surrounding  parts, 
by  inflammation,  is  owing  to  the  difference  in  the  state  of  the  constitu- 
tional health  of  those  affected  with  it. 

Where  a  puriform  state  of  the  secretions  is  complicated  with  ulcera- 
tion of  the  membrane,  the  matter  will  have  mixed  with  it  a  greater  or 
less  quantity  of  flocculi,  sometimes  of  so  firm  a  consistence  as  to  block 
up  the  nasal  opening  and  prevent  its  exit.  Mr.  Thomas  Bell  says  he 
has  seen  more  than  one  case  in  which  a  considerable  accumulation  had 
taken  place  in  the  antrum,  accompanied  by  the  usual  indications  of 
this  affection  (muco-purulent  engorgement  of  the  sinus),  when  a  sudden 
discharge  of  the  contents  into  the  nose  took  place,  "  in  consequence  of 
the  pressure  having  overcome  the  resistance  which  had  thus  been  offered 
to  its  escape."  Cases  of  a  very  similar  nature  have  fallen  under  our 
observation ,  the  history  of  one  of  which  will  be  given  in  the  course  of 
this  chapter.  The  formation  of  these  flocculi  rarely  ceases,  except  with 
the  cure  of  the  ulcers  on  the  membrane.  They  give  rise  to  considerable 
irritation,  and  their  presence  always  constitutes  an  obstacle  to  the  cure. 
They  are  usually  removed  by  injections. 

The  pituitary  membrane  of  the  antrum,  when  in  a  healthy  state, 
secretes,  as  we  have  before  stated,  a  transparent,  slightly  viscid  and 
inodorous  fluid,  poured  out  only  in  sufficient  quantity  to  lubricate  the 
cavity.  But  when  inflammation  is  excited  in  the  membrane,  its  secre- 
tions soon  become  more  abundant,  and  are  at  first  thinner,  afterward 


DISEASES   OF   THE   ANTRUM.  609 

thicker  and  more  glutinous.  Tlieir  color  and  consistence  are  not  always 
the  same.  Instead  of  being  transparent,  they  sometimes  have  a  dirty, 
opaque  appearance;  at  other  times  they  assume  a  greenish,  Avhitish,  or 
yellowish  color,  and  in  some  instances  they  bear  a  considerable  resem- 
blance to  pus,  which,  it  has  been  conjectured,  might  be  owing  to  sup- 
puration of  some  of  the  mucous  follicles  and  a  mixture  of  pus  with  its 
secretions.  Mr.  Thomas  Bell,  however,  inclines  to  the  opinion  that  it 
is  attributable  to  an  "  alteration  simply  "  of  the  secretions  of  the  cavity. 
Their  color  and  consistence  are  determined  by  the  degree  of  inflam- 
mation ;  the  length  of  time  it  has  existed ;  the  state  of  the  health  of 
the  lining  membrane,  and  that  of  the  surrounding  osseous  walls ;  the 
egress  which  the  matter  has  from  the  sinus ;  and  the  general  habit  of 
the  body. 

Affections  of  this  sort  are  more  common  to  young  subjects  than  to 
middle-aged  or  persons  in  advanced  life.  An  eminent  French  writer 
says  that  of  three  individuals  affected  with  dropsy  (mucous  engorge- 
ment), the  oldest  was  not  twenty  years  of  age. 

Symjytoms. — The  diagnoses  of  the  several  affections  of  the  antrum 
are  so  much  alike,  that  it  is  often  difficult  to  distinguish  those  that 
belong  to  one  from  those  attendant  upon  another.  The  symptoms  of 
mucous  engorgement  and  purulent  accumulation,  however,  are  gener- 
ally such  as  will  enable  the  practitioner  to  distinguish,  with  considerable 
certainty,  these  from  other  affections.  They  are  always  preceded  by 
inflammation  of  the  lining  membrane ;  a  description  of  the  symptoms 
of  which,  having  already  been  given,  need  not  be  repeated.  Omitting 
these,  we  at  once  proceed  to  mention  those  by  which  they  are  accom- 
panied. 

In  speaking  of  the  symptoms  more  particularly  belonging  to  a  pui-u- 
lent  condition  of  the  secretions  of  the  antrum,  Deschamps  says  the 
affection  may  be  distinguished  by  dull,  heavy  pain,  extending  along  the 
alveolar  border.  Upon  this  symptom  alone  little  reliance  can  be 
placed,  as  it  is  always  present  in  chronic  inflammation.  In  addition 
to  this,  he  mentions  the  presence  of  decayed  teeth  ;  soreness  in  those 
that  are  sound ;  and,  on  the  patient's  inclining  his  head  to  the  side 
opposite  to  the  one  affected,  the  discharge  of  fetid  matter  from  the  nose. 
These  are  very  conclusive  indications  of  purulent  effusions  in  this  cavity. 
Borden ave,  after  enumerating  the  symptoms  indicative  of  inflammation, 
mentions  the  following  as  belonging  to  the  affection  of  which  we  are 
now  speaking :  dull  and  constant  pain  in  the  sinus,  extending  from 
the  maxillary  fossse  to  the  orbit ;  a  discharge  of  fetid  matter  from 
the  nose,  when  the  patient  inclines  his  head  to  the  opposite  side,  or 
when  the  nose  is  blown  from  the  nostril  of  the  affected  side.  These 
symptoms  are  mentioned  by  almost  every  writer  upon  the  subject, 

39 


610  DENTAL   SURGERY. 

as  indicative  of  a  purulent  condition  of  the  secretions  of  the  max- 
illary sinus. 

The  symptoms  of  engorgement  differ  materially  from  those  which 
denote  simply  a  purulent  condition  of  the  mucous  secretions.  The 
pain,  instead  of  being  dull  and  heavy,  as  just  described,  becomes  acute, 
and  a  distressing  sense  of  fullness  and  weight  is  felt  in  the  cheek,  accom- 
panied by  redness  and  tumefaction  of  the  integument  covering  the 
antrum.  The  nasal  opening  having  become  closed,  the  fluids  of  the 
cavity  gradually  accumulate  until  they  fill  it;  when, finding  no  egress, 
they  press  upon  and  distend  the  surrounding  osseous  walls,  causing 
those  parts  which  are  the  thinnest  ultimately  to  give  way.  The  effects 
are  generally  .first  observable  anteriorly  beneath  the  malar  prominence, 
where  a  smooth,  hard  tumor  presents  itself,  covered  with  the  mucous 
membrane  of  the  mouth.  But  this  is  not  always  the  point  which  first 
gives  way.;  the  sinus  sometimes  bursts  into  the  orbit,  at  other  times 
outwardly  through  the  cheek,  or  through  the  palatine  arch.  The  long- 
continued  pressure  thus  exerted  upon  the  bony  walls  often  causes  the 
breaking  down  or  softening  of  their  tissues. 

The  tumor,  which  is  at  first  hard,  becomes  in  a  short  time  so  soft  as 
readily  to  yield  to  pressure.  A  distention,  Deschamps  says,  may  be 
distinguished  from  other  diseases  that  affect  the  skin  or  subcutaneous 
tissues  by  the  uniformity  or  regularity  of  the  tumor,  its  firmness  at 
the  commencement,  the  slowness  with  which  it  progresses,  and,  above 
all,  by  the  natural  appearance  of  the  skin,  and  the  absence  of  pain 
when  pressure  is  made  upon  the  tumor.  Obliteration  of  the  nasal 
opening,  he  says,  may  be  suspected  by  the  dryness  of  the  nostril  of  the 
affected  side,  the  mucous  membrane  of  which  becomes  thickened  and 
the  cavity  contracted,  inflammation  and  sponginess  of  the  gums,  loosen- 
ing and,  sometimes,  in  consequence  of  the  destruction  of  their  sockets, 
displacement  of  the  teeth,  may  also  be  mentioned  as  occasional  accom- 
paniments of  engorgement. 

Causes. — Inflammation  of  the  mucous  membrane  is  the  cause  of 
a  purulent  condition  of  the  secretions  of  the  maxillary  sinus,  and  this 
arises  more  frequently  from  a.lveolo-dental  irritation  than  from  any 
particular  habit  of  body  or  constitutional  disturbance.  Engorgement 
results  from  the  obliteration  of  the  nasal  opening,  which,  in  the  case  of 
altered  secretion,  is  usually  caused  by  inflammation  and  thickening 
of  the  lining  membrane. 

Treatment. — The  curative  indications  of  muco-purulent  secretion 
and  engorgement  of  the  maxillary  sinus  are,  firstly,  if  the  nasal  open- 
ing be  closed,  the  evacuation  of  the  retained  matter ;  secondly,  the  re- 
moval of  all  local  and  exciting  causes  of  irritation  ;  thirdly,  and  lastly, 
the  restoration  of  the  lining  membrane  to  its  normal  function. 


DISEASES    OF   THE    ANTRUM.  611 

For  the  fulfillment  of  the  first,  an  opening  must  be  made  into  the 
antrum,  and  this  should  be  effected  in  that  part  which  will  aff'ord  the 
most  easy  exit  to  the  retained  matter.  Several  ways  have  been  pro- 
posed for  the  accomplishment  of  this  object;  and  before  we  proceed 
further,  it  may  not  be  amiss  to  notice  some  of  the  various  methods 
that  have  been  adopted  by  different  practitioners. 

With  regard  to  the  tooth  most  proper  to  be  extracted  authors  differ.' 
Cheselden  preferred  the  first  or  second  molar.  Junker  recommended 
the  extraction  of  the  first  or  second  bicuspid,  and  if  a  fistula  had 
formed,  to  enlarge  it  instead  of  perforating  the  floor  of  the  antrum. 
But -the  second  molar,  being  directly  beneath  the  most  dependent  part 
of  the  cavity,  is  the  most  suitable  tooth  to  be  removed.  If  this  be 
sound,  the  first  or  third  molar  or  either  of  the  bicuspids,  if  carious, 
may  be  extracted  in  its  stead,  and,  in  fact,  no  tooth  beneath  the  antrum, 
in  an  unhealthy  condition,  should  be  permitted  to  remain.  Heath 
recommends  the  extraction  of  the  first  molar  on  account  of  the  depth 
of  its  socket,  and  because  it  is  more  liable  to  decay  than  any  of  the 
other  teeth. 

An  opening  having  been  effected  through  the  palatine  cavity  of  a 
molar  tooth  into  the  antrum,  it  should  be  kept  open  until  the  health 
of  the  cavity  is  restored.  For  this  purpose,  a  sound,  bougie  or  canula 
adapted  to  the  purpose  may  be  introduced. 

When  the  natural  opening  is  closed,  the  first  indication,  as  has  been 
stated,  is  the  evacuation  of  the  matter ;  and  for  this  purpose  a  per- 
foration should  be  made  into  the  sinus,  and  the  most  proper  place  for 
effecting  this,  it  has  been  shown,  is  through  the  alveolar  cavity  of  the 
second  molar.  It  may,  however,  be  penetrated  from  that  of  either  of 
the  other  molars  or  bicuspids. 

The  perforation,  after  the  Extraction  of  the  tooth,  is  made  with  a 
straight  trocar,  which  will  be  found  more  convenient  than  those  usu- 
ally employed  for  the  purpose.  The  point  of  the  instrument,  having 
been  introduced  into  the  alveolus  through  which  it  is  intended  to  make 
the  opening,  should  be  pressed  against  the  bottom  of  the  cavity  in  the 
direction  toward  the  centre  of  the  antrum.  A  few  rotary 
motions  of  the  instrument  will  suffice  to  pierce  the  inter-  ^^*^-  ^^°' 
veniug  plate  of  bone. 

Fig.  418  represents  Trephines  for  opening  the  antrum,  either 
through  the  palatine  cavity  of  a  second  or  first  molar,  or 
through  the  alveolus  between  these  two  teeth. 

If  the  first  opening  be  not  sufficiently  large,  its  dimensions 
may  be  increased  to  the  necessary  size  by  means  of  a  spear- 
pointed  instrument.  The  entrance  is  usually  attended  with 
a  momentary  severe  pain,  and  the  withdrawal  of  the  instru- 


612  DENTAL  SURGERY. 

ment  followed  by  a  sudden  gush  of  fetid  mucus.  In  introducing  the 
trocar,  care  should  be  taken  to  prevent  a  too  sudden  entrance  of  the 
instrument  into  the  cavity.  Without  this  precaution,  it  might  be 
suddenly  forced  against  the  opposite  wall.  It  is  not  always  necessary 
to  perforate  the  floor  of  the  antrum  after  the  extraction  of  the  tooth  ; 
it  occasionally  happens,  as  has  already  been  remarked,  that  some  of 
•the  alveolar  cavities  communicate  with  it. 

An  opening  having  thus  beeu  effected,  it  should  be  prevented  from 
closing  until  a  healthy  action  is  established  in  the  lining  membrane, 
and  for  this  purpose  a  bougie,  or  leaden  or  silver  canula,  or,  still  better, 
a  small  metal  plate,  fitted,  by  impression  and  dies,  to  the  portion  of  the 
ridge  about  the  opening,  with  a  small  tube  attached  to  fill  the  aperture, 
to  facilitate  the  flow  of  matter,  syringing,  and  as  a  preventive  to  the 
premature  closure  of  the  opening,  may  be  inserted  into  the  opening  and 
secured  to  one  of  the  adjacent  teeth.  It  should,  however,  be  removed 
for  the  evacuation  of  the  secretions  at  least  twice  a  day.  The  formation 
of  an  opening  at  the  base  or  most  dependent  part  of  the  sinus  will,  in 
those  cases  where  a  fistula  has  been  previously  formed,  be  followed,  in 
most  instances,  by  its  speedy  restoration.  Having  proceeded  thus  far, 
the  cure  will  be  aided  by  the  employment  of  such  general  remedies  as 
may  be  indicated  by  the  state  of  the  general  health  ;  and  for  the  dis- 
persion of  the  local  inflammation,  leeches  to  the  gums  and  cheeks  will 
be  found  serviceable.  The  antrum  may,  in  the  meantime,  be  injected 
with,  at  first,  some  mild  or  bland  fluid,  and  afterward  with  gently 
stimulating  liquids.  Diluted  port  wine,  weak  solutions  of  the  sulphate 
of  zinc  and  rose-water,  copper  and  rose-water,  or  permanganate  of 
potash,  answer  admirably,  especially  the  latter,  in  the  proportion  of  two 
grains  to  the  ounce  of  water.  Diluted  tincture  of  myrrh  may  some- 
times be  advantageously  employed,  and  when  the  membrane  is  ulcer- 
ated, a  solution  of  nitrate  of  silver  will  be  highly  serviceable.  The 
author  has  used  a  solution  of  iodide  of  potassium  with  advantage,  also 
a  weak  alcoholic  solution  of  tannic  acid  and  diluted  tincture  of  iodine. 
After  the  use  of  the  permanganate  of  potash,  a  carbolic  solution,  ^j  to 
water  5viij,  or  the  antiseptic  preparation  listeriue,  may  be  used  as  an 
injection  with  decided  benefit.  The  injection  of  a  warm  solution  of 
salt  and  water  is  highly  recommended  as  a  preparatory  step  before 
making  use  of  the  permanganate  of  potash  and  the  carbolic  solution. 
For  correcting  the  fetor  of  the  secretions,  a  weak  solution  of  the 
chlorinated  soda  or  lime,  or  a  solution  of  permanganate  of  potash,  may 
be  occasionally  injected  into  the  antrum. 

In  cases  of  simple  muco-purulent  secretion,  a  weak  decoction  of 
galls  may  be  injected  into  the  sinus  with  advantage.  Injections  of  a 
too  stimulating  nature  are  sometimes  employed.     This  should  be  care- 


DISEASES    OF    THE    ANTRUM.  613 

fully  guarded  against,  by  making  thcra  at  first  weak,  and  afterward 
increasing  their  strength  as  occasion  may  require  ;  and  if  symptoms 
of  a  violent  character  are  by  this  means  produced,  they  should  be 
combated  by  applying  leeches  to  the  gums  and  fomentations  to  the 
cheek. 

Dependent  as  these  affections  in  most  instances  are  upon  local  irri- 
tants, greater  reliance  is  to  be  placed  upon  their  removal  and  giving 
vent  to  the  acrid  puriform  fluids,  than  on  any  therapeutical  efiects 
exerted  upon  the  cavity  by  injections.  As  adjuvants,  they  are  ser- 
viceable, but  cure  cannot  be  effected  while  the  exciting  cause  remains 
unremoved. 

Dr.  Frank  Abbott  recommends  the  thorough  washing  out  of  the 
antrum,  immediately  after  an  opening  is  made  into  it,  with  a  warm 
solution,  consisting  of  a  teaspoonful  of  salt  to  half  a  pint  of  water, 
injected  with  slight  force,  and,  if  there  is  still  an  offensive  odor,  to 
syringe  with  the  permanganate  of  potash  solution  ;  then  with  the  car- 
bolic solution,  or  with  listerine ;  and  as  a  dressing,  to  be  renewed  daily, 
carbolized  oil  (1  part  of  carbolic  acid  to  15  parts  of  oil  of  sweet 
almonds),  on  cotton,  so  applied  that  it  may  be  retained  in  the  antrum, 
and  secured  by  attaching  it  to  a  tooth  or  to  a  plate  worn  in  the  mouth. 
If  no  improvement  is  apparent  after  two  or  three  days,  the  antrum  is 
to  be  syringed  Avith  a  solutiiDn  consisting  of  one  drachm  of  carbolic 
acid,  one  ounce  of  tincture  of  iodine  and  eight  ounces  of  water  ;  and  in 
some  cases  wuth  a  more  powerful  stimulant,  such  as  ten  grains  of 
chloride  of  zinc  to  one  ounce  of  water.  For  systemic  treatment,  he 
recommends  sulphide  of  calcium,  one-tenth  of  a  grain  pill  three  times 
a  day,  after  meals,  doubling  the  dose  if  necessary. 

The  following  cases  may  serve  to  illustrate  the  treatment  usually 
pursued  in  this  disease. 

Case  1. — Mrs.  T.,  a  married  lady,  about  forty  years  of  age,  of  a 
bilious  temperament,  applied  to  the  author  for  advice  in  1853.  She 
had  suffered  from  neuralgic  pains  in  her  face  and  temples,  at  intervals, 
for  nearly  twenty  years,  and  as  all  of  her  teeth,  especially  of  the  upper 
jaw,  were  so  much  decayed  as  to  preclude  the  possibility  of  restoration, 
he  urged  their  immediate  removal.  She  submitted  to  the  operation, 
hoping  that  it  would  relieve  her  from  the  pain  to  which  she  had  so 
long  been  a  martyr,  and  intending  to  have  the  lost  organs  replaced 
with  an  artificial  set.  She  called  again  in  a  few  months,  partly  for 
this  purpose,  and  partly  to  obtain  relief  from  pain  which  she  still 
experienced.  It  was  not  now  so  much  diffused  as  formerly,  but  was 
almost  wholly  confined  to  the  left  side  of  the  face.  On  inquiry  it  was 
ascertained  that  fetid  matter  was  occasionally  discharged  from  the 
nostril  of  the  aflTected  side.     This  led  him  to  suspect  that  the  antrum 


614  DENTAL  SURGERY. 

was  diseased.  An  opening  was  accordingly  made  through  the  alveolar 
border,  at  the  point  originally  occupied  by  the  second  molar.  The 
withdrawal  of  the  instrument  was  followed  by  the  discharge  of  a  small 
quantity  of  purulent  matter.  The  antrum  was  now  forcibly  injected 
with  water.  This  caused  the  discharge  of  more  than  two  tablespoonfuls 
of  hardened  flocculi  from  the  left  nostril,  which,  from  long  confine- 
ment, Avas  insufferably  offensive.  The  injection  was  repeated  until  the 
antrum  was  completely  freed  from  this  accumulation.  A  solution  of 
sulphate  of  zinc,  in  the  proportion  of  six  grains  to  the  ounce  of  water, 
was  now  substituted.  The  sinus  was  injected  daily  with  this  for  a 
little  more  than  a  week,  and  without  any  other  treatment  a  complete 
cure  was  effected. 

The  particulars  of  the  following  case  are  obtained  from  "  Observa- 
tions of  Bordenave  on  the  Diseases  of  the  Maxillary  Sinus,"  a  paper 
•  embodying  reports  of  forty  highly  interesting  cases. 

Case  2. — "In  1756,"  says  our  author,  "I  was  consulted  by  a  lady, 
whose  right  cheek  was  tumefied.  About  a  month  previously  she  had 
experienced  acute  pain  under  the  orbit  of  the  affected  side,  and  she 
felt  a  pulsation  and  heat  in  the  interior  of  the  sinus,  and  the  maxillary 
bone  was  slightly  elevated.  These  signs  determined  me  to  propose  the 
extraction  of  the  first  molar  tooth  and  the  perforation  of  the  antrum 
through  the  alveolus.  The  operation  was  followed  by  a  discharge  of 
purulent  matter,  the  sinus  was  afterward  injected,  the  maxilla  gradually 
reduced  itself,  and  a  cure  was  effected  in  about  two  months." 

Although  injections  were  employed  in  the  above  case,  it  was  no 
doubt  the  escape  of  the  matter  contained  in  the  antrum  to  which  the 
cure  was  attributable.  As  regards  the  cause  that  gave  rise  to  the 
affection  in  the  first  instance,  not  a  single  word  is  said.  It  may  have 
resulted  from  inflammation,  lighted  up  in  the  sockets  of  one  or  more 
teeth,  and  propagated  from  thence  to  the  mucous  membrane  of  this 
cavity,  or  from  inflammation  produced  by  some  other  cause,  and  a 
consequent  obliteration  of  the  nasal  opening. 

The  following  brief  statement  is  taken  from  the  history  of  a  case 
narrated  by  Fauchard  : — 

Case  3. — The  child  of  M.  Galois,  aged  twelve  years,  whose  first  right 
superior  molar  was  decayed,  had  a  tumor  situated  anteriorly  upon  the 
upper  jaw  of  the  same  side,  extending  up  to  the  orbit.  M.  Fauchard, 
supposing  this  tumor,  which  was  about  the  size  of  a  small  egg,  had 
been  caused  by  the  carious  tooth  in  question,  determined  on  its  extrac- 
tion as  the  only  means  of  effecting  a  speedy  and  certain  cure,  and  the 
result  proved  his  opinion  correct.  The  removal  of  the  tooth  was 
followed  by  a  large  quantity  of  yellow  serous  matter,  which,  on  exami- 
nation was  found  to  have  escaped  from  the  antrum.     The  tumor  dis- 


DISEASES    OF    THE    ANTRUM.  615 

appeared  soon  after  the  discharge  of  the  matter,  and  a  complete  cure 
was  effected. 

Bordenave,  in  noticing  the  foregoing  case,  does  not  believe  that  the 
tumor  communicated  with  the  maxillary  sinus,  for  the  reason  that  the 
matter  escaped  through  the  alveolus  of  the  first  molar  immediately 
after  its  extraction.  He,  however,  admits  that  the  acumen  and  knowl- 
edge of  Fauchard  are  such  as  to  have  prevented  deception  in  the  case. 
Admitting,  then,  the  statement  to  be  correct — and  surely  the  circum- 
stance mentioned  by  Bordenave  does  not  in  the  least  tend  to  invalidate 
it,  for  it  is  of  frequent  occurrence — a  cure  was  effected  simply  by  the 
removal  of  a  decayed  tooth,  to  the  irritation  produced  by  which  the 
disease  was  undeniably  attributable.  The  two  following  cases  are 
described  at  length  by  the  last-named  author,  in  the  "  Memoires  de 
I'Academie  Royale  de  Chirurgie." 

Case  4. — A  girl,  aged  twenty-six  years,  had  a  very  much  decayed  and 
painful  superior  dens  sapientise  on  the  right  side  extracted  ;  the  tooth 
was  broken,  and  all  the  roots  but  one  were  left  in  their  sockets.  These 
caused  an  abscess  to  form  ;  and  this  was  followed,  for  a  short  time,  by 
a  subsidence  of  the  pain,  which,  however,  soon  returned,  and  a  dull, 
heavy  sensation  was  felt  in  the  antrum  of  the  affected  side.  From 
thence  the  pain .  extended  to  the  eye  and  ear.  The  gums  at  length 
became  tumefied  and  the  pain  less  constant ;  the  patient  remained  in 
this  condition  for  five  years,  during  which  time  five  teeth  were  extracted. 
At  this  time  (1756),  M.  Beaupreau,  who  was  consulted,  found,  on 
examination,  that  the  gums  where  the  first  tooth  had  been  extracted 
had  not  entirely  united,  and  a  small  tubercle  had  formed,  from  which 
a  fluid  of  a  bad  smell  and  reddish  color  was  discharging  itself.  He 
introduced  a  probe  into  the  fistulous  hole  of  the  tubercle,  which,  after 
having  overcome  some  obstacle  that  af  first  impeded  its  passage,  pene- 
trated the  antrum.  The  opening  was  enlarged  and  mercurial  water 
applied  to  the  carious  bone;  but  it  soon  closed,  and  the  pain,  which 
had  ceased,  returned.  Injections  then  were  resorted  to,  which  dis- 
charged themselves  in  part  through  the  nasal  opening,  and  the  patient 
continued  in  this  way  until  an  exfoliation  of  the  bone  took  place,  when 
a  cure  was  effected. 

The  cause  of  the  disease  in  this,  as  in  the  preceding  cases,  was 
alveolo-dental  irritation,  and  a  cure  would  at  once  have' been  accom- 
plished by  the  removal  of  the  roots  of  the  tooth  that  had  been  left  in 
their  sockets;  this  was  proven  by  the  fact  that  it  was  not  until  they 
were  thrown  off  with  their  exfoliated  alveoli  that  the  disease  was 
subdued. 

In  alluding  to  these  and  similar  cases,  Bordenave  concludes  there 
are  not  many  cases  where  the  extraction  of  teeth  simply  will  suffice  to 


616  DENTAL  SURGERY. 

effect  a  cure.  This  inference,  to  say  the  least  of  it,  is  unfair;  for  in  the 
case  last  given,  the  disease  was  attributable  to  the  presence  of  the  roots 
of  a  tooth  that  had  been  fractured  in  an  attempt  to  extract  it,  and  left 
in  their  sockets,  and  we  have  good  reason  to  believe  that  the  cure  was 
wholly  owing  to  their  removal. 

Case  5. — Mr.  G ,  a  laborer,  about  thirty  years  old,  of  a  decidedly 

scorbutic  habit,  applied,  in  the  spring  of  1834,  to  an  eminent  physician 
of  Baltimore,  to  obtain  his  advice  concerning  an  affection  of  the  left 
side  of  his  face,  under  which  he  had  been  laboring  for  several  months. 
The  physician,  after  having  examined  the  case,  came  to  the  conclusion 
that  it  was  mucous  engorgement  of  the  maxillary  sinus,  and  requested 
him  to  call  upon  us,  and  have  one  of  his  molar  teeth  extracted  and 
the  floor  of  the  antrum  pierced  through  its  alveolus.  He  at  the  same 
time  desired  that  if  his  opinion  in  regard  to  the  nature  of  the  disease 
proved  to  be  correct,  we  should  take  charge  of  the  case  altogether.  On 
examining  his  mouth,  we  discovered  that  nearly  all  the  teeth  of  both 
jaws,  the  gums  and  alveoli,  were  extensively  diseased  ;  and,  on  inquiry, 
obtained  from  him  the  following  statement  with  regard  to  the  com- 
mencement and  progress  of  the  affection. 

About  six  months  before  this  time,  having  been  exj^osed,  while  pur- 
suing his  ordinary  avocations,  to  very  inclement  and  changeable 
weather,  he  contracted  a  severe  cold ;  in  consequence  of  this  he  was 
confined  to  his  bed  for  several  days,  during  which  time  he  was  twice 
bled,  took  two  cathartics  and  other  medicines. 

The  disease  at  first  settled  in  his  head,  face  and  jaws,  but  at  the 
expiration  of  eight  or  ten  days  was  subdued  by  the  above  treatment, 
with  the  exception  of  the  pain  in  his  left  cheek,  and  soreness  in  the 
upper  teeth  of  the  same  side.  The  pain  in  his  cheek,  although  not 
constant,  still  continued  ;  the  nasal  cavity  of  that  side  ceased  to  be  sup- 
plied with  its  usual  secretion,  the  teeth  became  more  sensitive  to  the 
touch  ;  finally,  at  the  end  of  four  months,  a  slight  protuberance  of  the 
cheek  was  observable,  accompanied  by  a  tumor  upon  the  left  side  of 
the  palatine  arch,  which  when  we  first  saw  him,  had  attained  to  half 
the  size  of  a  black  walnut ;  and  it  was  by  the  fiuctuation  felt  here  that 
the  physician  whom  he  first  consulted  was  induced  to  suspect  the  true 
nature  of  the  disease. 

Acting  in  consultation  with  the  medical  gentleman  in  whose  care 
the  patient  had  placed  himself,  w^e  extracted  the  second  left  superior 
molar  ;  then,  through  its  alveolus,  penetrated  the  antrum  by  means  of 
a  straight  trocar,  after  the  withdrawal  of  which  a  large  quantity  of 
glairy,  fetid,  mucous  fluid  was  discharged.  The  perforation  was  kept 
open  by  means  of  a  bougie,  secured  with  a  slight  ligature  to  an  adjoin- 
ing tooth,  as  recommended  by  Deschamps,  and  the  antrum  injected 


DISEASES    OF   THE    ANTRUM.  617 

three  times  a  day,  at  first  simply  with  rose-water,  to  which  a  small 
quantity  of  sulphate  of  zinc  was  afterward  added.  By  this  treatment 
the  lining  membrane  of  the  antrum,  at  the  expiration  of  five  weeks, 
was  restored  to  health,  and  the  secretions  that  escaped  through  the 
perforation  no  longer  exhaled  a  fetid  odor. 

The  patient,  not  experiencing  any  inconvenience,  withdrew  the 
bougie,  and  allowed  the  aperture  to  close.  In  about  two  months,  he 
again  presented  himself  to  the  author  similarly  affected  as  when  we  first 
saw  him.  We  now  extracted  the  first  superior  left  molar  and  perforated 
the  antrum  through  the  alveolus,  and  a  quantity  of  fetid  mucous  fluid 
was  again  discharged  ;  the  dens  sapientise  and  the  first  and  second 
bicuspids  of  the  affected  side,  being  carious,  were  also  extracted.  In- 
jections of  sulphate  of  zinc  and  rose  water,  diluted  tincture  of  myrrh, 
diluted  port  wine,  and  a  decoction  of  nutgalls,  were  alternately  era- 
ployed  for  three  months  ;  at  the  expiration  of  this  time  the  nasal  open- 
ing, which  had  been  previously  closed,  was  re-established,  and  a  perfect 
cure  effected. 

The  condition  of  the  teeth,  in  the  case  just  narrated,  may  not  be 
thought  to  have  exerted  any  agency  in  the  production  of  the  affection 
of  the  antrum,  but  the  following  considerations  would  seem  to  justify 
a  different  conclusion.  The  presence  of  decayed  teeth  beneath  the 
sinus  may  not  only  have  contributed  to  aggravate  the  morbid  action 
lighted  up  by  the  cold  which  he  had  taken,  but  may  also  have  caused 
it  to  locate  itself  in  this  cavity  ;  and  the  fact  that  the  inflammation  of 
the  lining  membrane  and  the  obliteration  of  the  nasal  opening  con- 
tinued until  they  were  removed,  would,  at  least,  seem  to  warrant  such 
an  inference.  That  the  injections  were  beneficial,  we  do  not  doubt, 
but  that  the  cure  was  eflTected  by  them,  no  one,  we  think,  will  dare  to 
afiirm.  We  are  far  from  believing  that  the  presence  of  the  decayed 
teeth  was  the  sole  cause  of  the  disease  of  the  antrum ;  that  they  con- 
tributed to  and  protracted  it,  we  cannot  hesitate  to  believe;  still,  but 
for  the  increased  excitability,  and,  perhajDS,  actual  inflammation,  in- 
duced in  the  mucous  membrane  by  the  exposure  of  the  patient  to 
inclement  and  sudden  transitions  of  weather,  it  is  probable  the  sinus 
would  never  have  become  affected.  But,  on  the  other  hand,  we  think 
it  not  unlikely  that,  although  the  disturbance  may  have  originated 
from  this  cause,  no  very  serious  or  lasting  morbid  effect  would  have 
been  produced  if  the  teeth  and  alveoli  had  been  in  a  perfectly  healthy 
condition. 

The  particulars  of  the  following  highly  interesting  case  were  com- 
municated to  the  author  by  Dr.  L.  Roper,  of  Philadelphia,  in  a  con- 
versation which  he  had  with  him  in  1845. 

Case  6. — Miss  M ,  a  young  lady  from  the  West  Indies,  about 


618  DENTAL   SURGERY. 

fourteen  years  of  age,  had  a  fistulous  opening  beneath  the  right  orbit, 
communicating  with  the  maxillary  sinus.  By  means  of  a  probe  intro- 
duced through  the  opening  into  this  cavity,  the  apices  of  the  roots  of 
the  first  superior  molar  could  be  distinctly  felt. 

Medical  aid  was  sought  at  an  early  stage  of  the  disease,  but  as  no 
permanent  benefit  resulted  from  the  treatment  adopted,  the  young  lady, 
at  the  expiration  of  nine  months,  was  brought  by  her  father  to  Phila- 
delphia, and,  in  the  spring  of  1831,  placed  under  the  care  of  the  late 
Dr.  Physick.  He,  suspecting  that  the  aifection  of  the  antrum  had 
reseulted  from  and  was  still  kept  up  by  irritation  produced  by  the  first 
superior  molar  of  the  aflTected  side,  which  was  considerably  decayed, 
directed  her  to  be  taken  to  Dr.  Roper,  who,  concurring  with  him  in 
opinion,  at  once  extracted  the  carious  tooth.  The  operation  was  fol- 
lowed by  the  immediate  discharge  of  a  large  quantity  of  thick,  muddy 
and  greenish  matter.  The  fistula  under  the  orbit  soon  closed,  and, 
without  any  further  treatment,  a  perfect  cure  was  accomplished  in  the 
course  of  a  few  weeks. 

The  foregoing  are  all  the  particulars  which  we  could  obtain  con- 
cerning this  interesting  case.  We  have  no  doubt  that,  if  all  the  cir- 
cumstances connected  with  its  early  history  were  known,  it  would  be 
found  to  have  resulted  from  inflammation  of  the  lining  membrane  of 
the  antrum,  caused  by  irritation  in  the  socket  of  the  tooth  which  was 
extracted.  This  opinion  is  sustained  by  the  fact  that  this  tooth  was 
aflfected  with  caries,  and  that  its  removal  was  followed  by  the  imme- 
diate cure  of  the  disease. 

In  Bordenave's  collection  of  cases  of  disease  of  the  maxillary  sinus, 
published  in  the  Memoirs  of  the  Royal  Academy  of  Surgery,  there 
are  several  examples  similar  to  the  one  just  narrated.  We  subjoin  a 
description  of  the  two  following : — 

Case  7. — A  servant  of  the  Count  de  Maurepas  had  been  afflicted  for 
six  months  with  a  fistula  upon  the  left  cheek,  a  little  below  the  orbit, 
penetrating  to  the  maxillary  sinus,  and  caused  by  the  spontaneous 
opening  of  an  abscess  The  first  and  second  molars,  both  of  which  were 
considerably  decayed,  were  extracted  by  M.  Hevin,  As  there  were  no 
openings  through  the  alveoli,  he  perforated  one  with  a  trocar ;  this 
opening  gave  vent  to  a  great  quantity  of  putrid  sanies,  and  did  not 
close  for  more  than  a  year  after  it  was  made.  The  fistula  of  the  cheek 
healed  in  about  ten  days. 

Case  8. — In  1717,  a  soldier  of  the  regiment  of  Bassigny,  who  had 
for  a  long  time  a  fistula  in  his  cheek  penetrating  into  the  maxillary 
sinus,  was  treated  for  it  at  the  Hotel  Dieu,  of  Montpellier.  The  matter 
settling  near  the  orifice  of  the  fistula  prevented  it  from  closing.  M. 
Lamourier,  on  examining  the  mouth  of  the  soldier,  perceived  that  the 


CAEIES   OF   THE   MAXILLARY   BONES.  619 

second  superior  molar  was  decayed ;  this  he  extracted,  and  profited  by 
the  alveolar  cavity  to  make  an  opening  into  the  base  of  the  sinus.  The 
fistula  of  the  cheek  was  by  this  means  cured  in  a  few  days,  but  the 
counter  opening  was  not  immediately  permitted  to  close. 

In  cases  of  fistula  resulting  simply  from  engorgement  of  the  sinus, 
the  treatment  should  consist,  as  in  the  foregoing  cases,  in  the  formation 
of  a  counter  opening,  which  should  always  be  efiected  at  the  most  de- 
pendent part  of  the  cavity ;  and  next  in  the  removal  of  all  sources  of 
local  irritation ;  lastly,  in  the  employment  of  suitable  injections. 

In  the  cases  thus  far  presented,  we  have  selected  such  as  were  not 
complicated  with  abscess,  ulceration  of  the  lining  membrane,  or  caries 
of  the  surrounding  osseous  walls ;  but  to  the  existence  of  the  two  last 
the  aflections  of  which  we  have  been  treating,  often  give  rise.  For 
tumors,  etc.,  of  the  antrum,  the  reader  is  referred  to  "Tumors  of  the 
Gums." 


CHAPTER  X. 

CARIES   OF   THE   MAXILLARY   BONES. 

CARIES  of  the  maxillse,  like  necrosis,  is  not  a  very  common  disease, 
and  differs  from  the  latter  in  being  analogous  to  ulceration  in  the 
soft  parts,  and  in  being  free  from  the  odor,  when  cleanliness  is  observed, 
which  characterizes  necrosis. 

The  symptoms  of  caries  of  bone  resemble  those  of  alveolar  abscess, 
and  when  the  acute  form  of  the  disease  is  present,  it  is  associated  with 
inflammation  of  the  gums  and  dental  periosteum  ;  periostitis  being 
early  manifested  when  the  carious  condition  of  the  bone  results  from 
diseased  teeth.  When,  caries  of  the  maxillse  is  well  established,  one  or 
more  fistulous  openings  exist  in  the  gum  or  in  some  adjacent  part ; 
these  openings  being  surrounded,  in  the  majority  of  cases,  by  fungous 
granulations.  The  bone  beneath  is  full  of  minute  cells,  and  is  of  a 
soft  consistence — a  condition  readily  detected  by  the  probe  or  an  exca- 
vator, and  differing  very  materially  from  the  solid,  resisting  structure 
presented  by  bone  when  in  a  normal  condition.  Commencing  like 
ordinary  periostitis,  there  is  present,  in  the  early  stage,  increased  vas- 
cularity and  congestion,  which  terminates  in  ulceration ;  the  bone  cells 
becoming  enlarged  by  the  breaking  down  of  their  walls,  and  filled 
with  semi-organized  lymph,  the  accumulation  of  which  is  attended 
with  a  rapid  advance  of  the  destructive  process.  The  numerous,  irregu- 
lar cavities  existing  in  the  bone  are  lined  by  a  glazed  secreting  surface. 


620  DENTAL   SURGERY. 

According  to  Virchow,  "the  bone  breaks  up  in  its  territories,  the  indi- 
vidual corpuscles  undergo  new  developmental  changes  (granulation 
and  suppuration),  and  remnants  composed  of  the  oldest  basis  substance 
remain  in  the  form  of  small,  thin  shreds  in  the  midst  of  the  soft 
substance.  In  ossification  (in  cartilage)  there  is  a  portion  of  the 
original  intercellular  substance  of  the  cartilage  cells  (secondary  cells), 
which,  though  it  belongs  to  the  group  as  a  whole,  yet,  when  these,  in 
the  course  of  ossification,  are  transformed  into  a  number  of  isolated 
bone  cells,  becomes,  comparatively  speaking,  almost  entirely  independ- 
ent of  those  cells  individually,  and  therefore  escapes  the  changes  which 
befall  them." 

It  is  this  portion  which  remains  behind  in  caries,  while  the  secondary 
intercellular  substance  perishes.  "  At  the  moment  a  periosteal  tissue 
quits  the  surface  of  a  bone,  and  the  vessels  are  drawn  out  from  the 
cortex  in  inflammatory  condition,  we  see,  not  as  in  normal  bone, 
mere  threads,  but  little  plugs,  thicker  masses  of  substance ;  and  if 
they  have  been  entirely  drawn  out,  there  remains  a  disproportionately 
large  hole,  much  more  extensive  than  it  would  be  under  normal  cir- 
cumstances. On  examining  one  of  these  plugs,  you  will  find  that 
around  the  vessel  a  certain  quantity  of  soft  tissue  lies — the  cellular  ele- 
ments of  which  are  in  a  state  of  fatty  degeneration.  At  the  spot  where 
the  vessel  has  been  drawn  out,  the  surface  does  not  appear  even,  as  in 
normal  bone,  but  rough  and  porous ;  and  when  placed  under  the  micro- 
scope, you  remark  those  excavations,  those  peculiar  holes,  which  cor- 
respond to  the  liquefying  bone  territories.  If  it  be  asked,  therefore,  in 
what  way  bone  becomes  porous  in  the  early  stage  of  caries,  it  may  be 
said  that  the  porosity  is  certainly  not  due  to  the  formation  of  exuda- 
tions, seeing  that  for  these  there  is  no  room,  inasmuch  as  the  vessels 
within  the  medullary  canals  are  in  immediate  contact  with  the  osseous 
tissue.  On  the  contrary,  the  substance  of  the  bone  in  the  cellular  ter- 
ritories liquefies;  vacuities  form,  which  are  first  filled  with  a  soft  sub- 
stance, composed  of  a  slightly  streaky,  connective  tissue,  with  fatty, 
degenerated  cells.  The  whole  process  is  a  degenerative  ostitis,  in 
which  the  osseous  tissue  changes  its  structure,  loses  its  chemical  and 
morphological  character,  and  so  becomes  a  soft  tissue,  which  no  longer 
contains  lime." 

In  the  early  stage  of  caries  of  the  maxillise,  there  is  nothing  to  dis- 
tinguish it  from  dental  periostitis,  and  although  the  causes  of  this 
disease  are  various,  yet  one  of  the  most  common  is  the  presence  of 
dead  teeth  and  roots  of  teeth,  and  the  superior  maxilla  is  much  more 
prone  to  its  attacks  than  the  inferior,  and  especially  where  the  bone  is 
of  a  loose,  spongy  character,  as  in  the  strumous  and  mercurial  dia- 
thesis.    In  cases  of  ulceration  and  extensive  destruction  of  the  tissues 


CARIES    OF    THE    MAXILLARY    BONES.  621 

of  the  face,  resulting  from  syphilis  or  lupus,  the  maxillary  bones  may 
become  carious,  and  terrible  deformity  follow,  as  in  cases  where  it 
commences  in  the  palate,  and  destroying  it,  makes  a  common  cavity  of 
the  mouth  and  nose,  and  involves  the  face. 

Treatment. — In  the  early  stage  of  the  acute  form  of  caries  of  the 
bones  of  the  jaws,  such  antiphlogistic  remedies  as  cathartics,  diapho- 
retics, hot  foot  baths,  leeches  and  counter-irritants  may  be  resorted  to. 
If  a  diseased  tooth  or  teeth  give  rise  to  the  inflammation,  such  should 
be  removed  if  they  cannot  be  successfully  treated.  Blood  taken  from 
the  arm,  and  also  dry  cups,  are  often  serviceable.  If  a  depraved  con- 
dition of  the  system  is  present,  as  is  frequently  the  case,  the  disease 
being  of  an  asthenic  type,  such  constitutional  remedies  as  iron,  quinine, 
cod-liver  oil  and  like  tonics  are  indicated  ;  and  when  the  caries  is 
established,  injections  of  aromatic  sulphuric  acid  in  full  strength,  or 
the  officinal  sulphuric  acid,  one  part  to  six  or  eight  parts  of  water,  or, 
when  required,  in  equal  parts,  will  dissolve  the  carious  bone,  relieve 
the  irritation  caused  by  its  presence,  and  hasten  the  cure,  having  a 
stimulant  efifect  upon  diseased  tissues,  and  exerting  an  antiseptic  influ- 
ence. Listerine  may  also  be  employed  for  its  antiseptic  properties  in 
conjunction  with  the  aromatic  sulphuric  acid,  no  other  remedy  proving 
so  satisfiictory  in  the  treatment  of  this  disease  as  the  latter  agent. 
Other  agents,  in  the  form  of  injections,  have  also  been  recommended, 
such  as  carbolic  acid  solution,  tincture  of  iodine,  compound  tincture  of 
capsicum  and  chloride  of  zinc. 

The  removal  of  the  carious  bone  is  often  necessary  by  such  appli- 
ances as  rose-head  drills,  made  for  the  purpose  and  operated  by  the 
dental  engine,  chisels,  etc. 

An  incision  is  first  made  to  expose  the  bone,  and  the  carious  portion 
is  then  cut  away  with  the  rose-head  drill  or  chisel,  causing  but  little 
pain,  until  normal  structure  is  reached,  which  is  easily  distinguished 
by  the  diflference  in  touch  of  the  instrument.  Comparatively  slight 
hemorrhage  occurs,  as  a  general  rule,  and  it  is  readily  controlled  by 
such  styptics  as  a  saturated  solution  of  chloride  of  zinc,  Monsel's 
powder,  or  compression  by  means  of  hot  sponges.  In  employing  in- 
jections in  the  treatment  of  well-established  caries  of  bone,  great  benefit 
results  from  the  preparatory  cleansing  of  the  parts  with  warm  water, 
and  its  use  should  never  be  omitted. 


PART  FOURTH, 


MECHA]\TICS. 


MECHANICS. 


THIS  branch  of  dental  science  teaches  the  art  of  replacing  lost 
organs  of  the  Mouth,  or  any  lost  parts  thereof.  It  is  sometiraes 
called  dental  Prosthesis  (replacement).  Mechanical  detail  is  its  prevail- 
ing feature  ;  substitution,  or  replacement,  is  its  distinctive  peculiarity. 

Mechanical  detail  also  distinguishes  the  Surgery  of  dentistry  as 
compared  with  general  surgery  ;  but  as  a  branch  of  dentistry,  thera- 
peusis,  or  the  arrest  of  disease,  is  its  distinctive  peculiarity. 

The  one  treats  disease,  or  irregularity  of  the  natural  organs;  the 
other  substitutes  their  loss  by  artificial  ones.  Both  demand  a  skillful 
training  of  the  hands,  and  equally  require,  for  their  fullest  develop- 
ment, all  the  knowledge  comprehended  under  the  term  Dental  Science. 

Dental  Mechanics  includes  the  laws  and  principles  which  determine 
and  regulate  the  processes  employed  in  the  construction  of  all  forms 
of  dental  mechanism  ;  also,  the  properties  and  relations  of  all  materials 
used  in  these  processes.     It  gives  rules  for  the  replacement  of 

1.  Lost  teeth. 

2.  Lost  alveoli,  or  parts  thereof. 

3.  Lost  palate,  hard  and  soft,  or  parts  thereof 

The  first  division  is  the  most  important,  because  the  most  universally 
demanded. 

Prof.  Austen  gives  the  following  order  of  operations  in  the  Replace- 
ment OF  Lost  Teeth,  and  classification  of  the  various  styles  of  work. 

1.  Preparation  of  the  mouth  ;  including 
(a)  Treatment  of  the  mucous  membrane. 

(6)  Extraction  or  treatment  of  teeth  and  roots. 

2.  Impression  of  the  mouth  ;  including 

(a)  Form  and  material  of  impression  cups. 
(Z))  Description  of  impression  materials. 

(c)  Selection  and  manipulation  of  the  same. 

(d)  Preparation  for  the  model. 

3.  The  plaster  model ;  including 

(a)  General  directions  for  making  model. 
(6)  Special  forms  adapted  to  subsequent  uses, 
(c)  Removal  from  impression. 

(c?)  Preparation  for  the  operation  of  making  the  plate. 
40  625 


626  MECHANICS. 

4.  The  base-plate  ;  which  is  either 
(a)  Permanent,  in  swaged  work,  or 
(6)  Temporary,  in  plastic  work. 
The  subsequent   operations  differ  in  their  order  and  character  so 
widely  as  to  require  a  separate  classification  in 

(A)  Swaged  work : 

(1)  Metallic  die  and  counter-die,  made  by 

(a)  Sand  moulding ; 

(b)  Dipping,  or  pouring  ; 

(c)  Fusible  metal  process,  or  by 

{d)  Pouring  directly  into  the  impression. 

(2)  Refining  and  rolling  plate. 

(3)  Swaging  plate  (gold,  silver,  platinum,  or  aluminum). 

(4)  Articulating  impressions. 

(5)  Adjustment  on  articulator. 

(6)  Selection  and  fitting  of  teeth,  and 

(7)  Attaching  them  to  base-plate,  by 
(a)  Soldering ; 

(6)  Vulcanite;  Celluloid; 
(c)  Porcelain  continuous  gum. 

(8)  Finishing  process. 

(B)  Plastic  work : 

(1)  Temporary  plate  of 

(a)  Wax,  or  gutta-percha; 

(b)  Thick  tin,  or  lead,  foil. 

(2)  Articulating  impressions. 

(3)  Adjustment  on  articulator. 

(4)  Selection  and  fitting  of  teeth. 

(5)  Preparation  of  the  matrix. 

(6)  Moulding  and  hardening  of  the  base-plate,  made  of 
(a)  Vulcanite  compounds,  which  harden  by  heat ; 
(6)  Celluloid  compound,  which  hardens  by  heat ; 

(c)  Molten  tin  alloys,  which  harden  on  cooling ; 

(d)  Molten  and  swaged  aluminum  ; 

(7)  Which  process  at  the  same  time  attaches  the  teeth. 

(8)  Finishing  process. 

The  details  of  Swaged  work  vary  according  to  the  mode  of  making 
dies,  the  metal  chosen  for  the  plate,  and  the  manner  of  attaching 
the  teeth ;  but  the  order  of  operations  is  the  same.  The  details  of 
Plastic  work  vary  also,  according  to  the  material  composing  the  plate  ; 
but  the  order  of  operations  is  the  same — differing  from  the  former 
mainly  because  articulation  follows  the  formation  of  the  base-plate  iu 
one  case,  while  in  the  other  it  precedes  it. 


DENTAL   PROSTHESIS.  627 

These  differences  in  the  material  of  the  base-plate  give  rise  to  a 
classification  of  Swaged  work  into 

1.  Gold  plate; 

2.  Aluminum  plate  ; 

3.  Platinum  plate. 

The  first  (and  third)  allows  attachment  of  the  teeth  by  soldering ; 
the  second  demands  a  vulcanite  attachment ;  the  third  alone  permits, 
by  virtue  of  its  resistance  to  furnace  heat,  the  addition  of  a  continuous 
porcelain  gum. 

Plastic  work  is  divided  into 

1.  Vulcano-plastic ; 

2.  Cellulo-plastic. 

3.  Metallo-plastic ; 

4.  Ceramo-plastic. 

The  first  is  known  as  rubber  work  ;  the  second  is  known  as  celluloid 
work  ;  the  third  includes  cheoplastic  work,  the  old-fashioned  block- 
tin  base,  all  tin  alloys  and  cast  aluminum,  etc.;  the  fourth  is  known  as 
the  porcelain  base. 

In  Prosthetic  dentistry,  swaged  work  is  the  patrician  element ;  plastic 
work,  the  plebeian.  When  the  latter  runs  riot,  without  the  conservative 
influence  of  the  former,  the  power  of  the  people  becomes  a  power  for 
evil.  This  is  precisely  the  danger  which  now  threatens  dentistry,  in 
the  abuse  of  certain  most  valuable  processes  and  materials. 

Facility  of  construction  and  cheapness  of  material  have  encouraged 
a  style  of  practice  in  the  highest  degree  detrimental  to  the  profession. 
If  such  practice  is  inseparable  from  plastic  w^ork,  it  should  be  unhesi- 
tatingly abandoned  by  every  one  who  holds  the  honor  of  dentistry 
dear  to  him.  It  becomes  also  a  grave  question  how  far  the  present 
mania  for  patents  (another  abuse  of  a  valuable  privilege)  is  beneficial 
to  the  reputation  of  a  liberal  profession. 


CHAPTER  I. 

DENTAL  PROSTHESIS. 


CONTRIBUTING,  as  the  teeth  do,  to  the  beauty  and  expression  of 
the  countenance,  to  correct  enunciation,  and  through  improved 
facility  of  mastication,  to  the  health  of  the  whole  organism,  it  is  not 
surprising  that  their  loss  should  be  considered  a  serious  afiliction,  and 
that  art  should  be  called  upon  to  replace  such  loss  with  artificial  sub- 


628  MECHANICS. 

stitutes.  So  great,  indeed,  is  the  liability  of  the  human  teeth  to  decay, 
and  so  much  neglected  are  the  means  of  their  preservation,  that  few 
persons,  at  the  present  day,  reach  even  adult  age  without  losing  one  or 
more  of  these  invaluable  organs.  Happily  for  suffering  humanity, 
they  can  now  be  replaced  with  artificial  substitutes  so  closely  resembling 
the  natural  organs  as  to  be  readily  mistaken  for  them,  even  by  critical 
and  practiced  observers.  Although  there  is  a  perfection  in  the  work 
of  nature  that  can  never  be  equaled  by  art,  artificial  teeth  are  now  so 
constructed  as  to  subserve,  at  least  to  a  great  extent,  the  purposes  of 
the  natural  organs.  When  properly  adjusted,  they  are  worn  without 
the  slightest  discomfort ;  so  much  so,  in  many  cases,  that  the  patient, 
after  they  have  been  in  the  mouth  a  few  weeks,  is  scarcely  conscious  of 
their  presence. 

The  construction  of  artificial  teeth  is  an  operation  which,  though 
acknowledged  to  be  of  great  importance,  and  performed  by  every  one 
having  any  pretension  to  a  knowledge  of  dentistry,  is,  unfortunately, 
but  little  understood  by  the  majority  of  practitioners.  The  mouth  is 
often  irreparably  injured  by  their  improper  application.  A  single  arti- 
ficial tooth,  badly  inserted,  may  cause  the  destruction  of  the  two  adja- 
cent natural  teeth,  or  those  to  which  the  artificial  appliance  is  secured; 
and  if  the  deficiency  thus  occasioned  be  unskillfully  supplied,  it  may 
cause  the  loss  of  others ;  in  this  way  all  the  teeth  of  the  upper  jaw  are 
sometimes  destroyed. 

The  utility  of  artificial  teeth  depends  upon  their  proper  construction 
and  correct  application.  There  is  no  branch  of  dental  practice  that 
requires  more  skill  and  judgment,  or  more  extensive  and  varied  scien- 
tific information.  A  knowledge  of  the  anatomy  and  physiology  of  the 
mouth,  of  its  various  pathological  conditions,  and  their  therapeutical 
indications,  is  as  essential  to  the  mechanical  as  to  the  surgical  dentist. 
To  correct  information  upon  these  subjects  must  be  added  the  ability 
to  execute,  with  the  nicest  skill  and  most  perfect  accuracy,  all  the 
mechanism  required  in  dental  prosthesis. 

There  are  difiiculties  connected  with  the  insertion  of  artificial  teeth 
of  which  none  but  an  experienced  dentist  has  any  idea.  They  must  be 
constructed  and  applied  in  such  a  manner  that  they  may  be  easily  re- 
moved and  replaced  by  the  patient;  at  the  same  time  they  must  be 
securely  fixed  in  the  mouth,  and  be  productive  of  no  injury  to  the  parts 
with  which  they  are  in  relation. 

But  perfect  mechanism  is  not  the  sole  element  of  success;  often  it  is 
not  the  most  essential  one.  To  know  when  to  extract  and  when  to  re- 
tain a  root  or  a  tooth  ;  when  to  secure  a  piece  by  clasps  and  when  by 
simple  adaptation ;  when  to  use  gold  and  when  some  other  material ; 
to  determine  the  best  form  of  a  plate  and  the  proper  time  for  its  inser- 


DENTAL   PROSTHESIS.  629 

tion;  finally,  to  determine  when  and  what  prosthetic  skill  can  do,  when 
and  why  it  will  fail — are  a  few  of  the  problems  in  dental  mechanics 
which  demand  for  their  correct  solution  a  fullness  and  extent  of  in- 
formation which  are  not  always  brought  to  bear ;  perhaps  because, 
unfortunately,  the  necessity  is  not  recognized  as  it  should  be. 

Notwithstanding  the  triumphs  of  prosthetic  dentistry,  and  the  high 
state  of  excellence  to  which  it  has  arrived,  at  no  previous  time  was 
there  ever  so  much  injury  inflicted,  and  suffering  occasioned  by  arti- 
ficial teeth,  as  at  present,  resulting  solely  from  their  bad  construction 
and  incorrect  application.  That  such  should  be  the  case,  when  there 
are  so  many  scientific  and  skillful  dentists  in  every  city  and  in  many 
of  the  villages  of  the  country,  may  seem  strange,  but  the  fact  is  never- 
theless undeniable.  We  may  explain  it  in  part  by  the  very  rapidly 
increasing  demand  for  dental  services,  which  has  not  allowed  time  for 
the  development  of  intelligent  and  skilled  labor,  either  of  head  or  hand  ; 
in  part  also  by  the  universal  experience  that  all  new  professions  are 
full  of  immature  and  crude  material.  But  these  explanations  cannot 
long  be  received  in  excuse  for  a  state  of  things  which  ought  to  be 
rapidly  disappearing  ;  which  is,  in  fact,  giving  way  under  the  combined 
influence  of  our  colleges,  our  periodicals  and  text-books,  the  teachings 
and  example  of  our  eminent  practitioners,  and  the  more  appreciative 
judgment  of  the  public. 

These  remarks  apply  alike  to  the  surgery  and  mechanism  of  dentistry. 
The  latter  has  an  additional  barrier  to  progress  in  the  common  prac- 
tice of  delegating  the  greater  part  of  its  details  to  inexperienced,  unin- 
formed and  irresponsible  assistants.  Perfect  dentistry  demands  equal 
skill  and  education  in  both  departments.  Each  requires  that  its  com- 
plete series  of  operations  shall  be  the  work  of  one  person.  If,  therefore, 
the  work  of  the  two  are  so  far  incompatible  that  they  cannot  be  com- 
bined, the  separation  should  be  complete.  The  semi-mechanisiu  of  the 
surgeon  is  like  the  semi-surgery  of  the  mechanician.  Each  injures  an 
otherwise  perfect  reputation ;  both  do  harm  to  the  profession  they  seek 
to  honor. 

In  an  excellent  article  on  "  Temperament  in  Relation  to  the 
Teeth,"  *  Dr.  James  W.  White  writes  as  follows : — 

"  The  value  of  a  practical  application  of  the  study  of  temperament 
in  the  practice  of  dentistry  is  apparent.  That  the  relation  of  the  teeth 
to  temperament  is,  as  a  rule,  ignored  by  those  engaged  in  prosthetic 
dentistry  is  evident  in  the  mouths  of  a  majority  of  those  who  ai-e  so 
unfortunate  as  to  be  under  the  necessity  of  wearing  substitutes  for  lost 
natural  dentures. 

"  A  certain  law  of  harmony  in  nature  between  the  teeth  and  other 
*  Dental  Cosmos,  February,  1884. 


630  JiECHAisrics. 

physical  characteristics  necessitates  respect  to  size,  shape,  color,  and 
other  qualities  in  an  artificial  denture,  in  order  that  it  shall  corres- 
pond with  other  indications  of  temperament;  and  if  teeth  correlated  in 
their  characteristics  to  those  which  nature  assigns  to  one  temperament 
be  inserted  in  the  mouth  of  one  whose  physical  organization  demands 
a  different  type,  the  effect  is  abhorrent.  The  artificiality  of  artificial 
teeth  is  the  subject  of  remark  by  those  who  have  little  or  no  concep- 
tion of  the  reason  therefor — simply  an  instinctive  appreciation  of  the 
incongruity  and  unreality.  It  is  indeed  rare  to  see  a  case  in  which 
there  is  occasion  for  a  moment's  hesitation  as  to  the  fact  of  reiolacement. 
There  is  no  dental  service  that  from  the  sesthetic  standpoint  is,  as  a 
rule,  so  ill  performed  as  the  prosthetic.  Thousands  of  dentures  are 
constructed  which  serve  the  needs  of  the  wearer  for  speech  and  masti- 
cation, but  which  are  nevei'theless  deserving  of  utter  condemnation  as 
art  productions.  More  attention  has  been  paid  to  the  best  methods  of 
restoring  impaired  function — securing  comfort  and  usefulness  in  arti- 
ficial dentures — than  to  a  correlation  of  the  substitutes  to  the  physical 
chai'acteristics  of  the  patient, 

"  What  is  needed  is  such  an  appreciation  of  the  law  of  correspond- 
ence that  the  dentist  can  cipher  out,  as  by  the  rule  of  three,  the  char- 
acter of  teeth  required  in  the  case  of  an  edentulous  mouth,  with  the 
same  precision  as  the  comparative  anatomist  can  from  a  single  bone 
indicate  the  anatomical  structure  of  the  animal  to  which  it  belonged." 

We  shall  enumerate  some  of  the  difierent  kinds  of  dental  substitutes 
that  have  been  employed  since  the  commencement  of  the  present  cen- 
tury. We  shall  also  notice,  briefly,  the  principal  methods  that  have 
been  adopted  in  their  application,  before  entering  upon  a  minute 
description  of  those  practiced  at  the  present  time.  Great  improvements 
have  been  made  in  dental  prosthesis  since  the  publication  of  the  first 
edition  of  this  work.  In  fact,  no  science  or  art,  except  Chemistry, 
has  been  so  eminently  progressive  during  the  last  twenty  years  as 
Mechanical  Dentistry. 


DENTAL    SUBSTITUTES — HUMAN   TEETH.  631 


CHAPTER  II. 

SUBSTANCES    EMPLOYED    AS    DENTAL   SUBSTITUTES. 

THERE  are  two  qualities  which  it  is  highly  importaut  that  dental 
substitutes  should  possess.  They  should  be  durable  in  their  nature, 
and  in  their  appearance  should  resemble  the  natural  organs  which  they 
replace  or  with  which  they  are  associated. 

The  kinds  of  teeth  that  have  been  employed  since  1820  are  : — 

1.  Human  teeth. 

2.  Teeth  of  neat  cattle,  sheep,  etc. 

3.  Teeth  carved  from  the  ivory  of  the  elephant's  tusk,  and  from  the 
tooth  of  the  hippopotamus. 

4.  Porcelain  teeth. 

HUMAN   TEETH. 

As  regards  appearance,  which  in  a  dental  substitute  is  an  important 
consideration,  human  teeth  are  preferable  to  any  other,  except,  perhaps, 
the  almost  perfect  recent  productions  of  the  dento-ceramic  art.  When 
used  for  this  purpose,  they  should  be  of  the  same  class  as  those  the 
loss  of  which  they  are  to  replace.  The  crowns  only  are  employed,  and, 
if  well  selected  and  skillfully  adjusted,  the  artificial  connection  with 
the  alveolar  ridge  cannot  easily  be  detected. 

The  durability  of  these  teeth  when  thus  employed  depends  upon  the 
density  of  their  texture,  the  soundness  of  their  enamel,  and  the  condi- 
tion of  the  mouth  in  which  they  are  placed.  If  they  are  of  a  dense 
texture,  with  sound  and  perfect  enamel,  and  are  placed  in  a  healthy 
mouth,  they  will  last  from  eight  to  twelve  years,  or  even  longer.  The 
difficulty,  however,  of  procuring  these  teeth  is  generally  so  great  that 
it  is  seldom  that  such  as  we  have  described  can  be  obtained  ;  and  even 
when  they  can,  the  mouth,  in  half  the  cases  in  which  artificial  teeth 
are  placed,  is  not  in  a  healthy  condition ;  its  secretions  are  often  so 
vitiated  and  of  so  corrosive  a  nature,  that  they  destroy  them  in  less 
than  four  years.  We  have  even  known  them  to  be  destroyed  in  two, 
and  in  one  case  in  fifteen  months. 

A  human  tooth,  artificially  applied,  is  more  liable  to  decay  than 
one  of  equal  density  having  a  vital  connection  with  the  general  system, 
for  the  reason  that  its  dentinal  structure  is  more  exposed  to  the  action 
of  deleterious  chemical  agents.  Yet  of  all  the  animal  substances 
employed  for  this  purpose,  human  teeth  are  unquestionably  the  best. 
They  are  harder  than  bone,  and  being  more  perfectly  protected  by 


632  MECHANICS. 

enamel,  are  consequently  more  capable  of  resisting  the  action  of  cor- 
rosive agents. 

Many  object  to  having  human  teeth  placed  in  the  mouth,  under  the 
belief  that  infectious  diseases  may  be  communicated  by  them.  But 
the  purifying  process  to  which  they  are  previously  submitted  greatly 
diminishes  this  danger.  When  the  practice  of  transplanting  teeth 
was  in  vogue,  occurrences  of  this  sort  were  not  unfrequent;  but  since 
that  has  been  discontinued,  these  have  seldom  if  ever  happened.  Still, 
the  prejudice  against  human  teeth  is  so  strong  that  it  is  impossible,  in 
most  cases,  to  overcome  them.  This  feeling,  the  difficulty  of  procuring 
them,  the  high  price  they  command,  and  their  want  of  durability, 
have  gradually  led  to  their  entire  disuse,  which  is  scarcely  to  be  re- 
gretted, now  that  art  can  produce  in  porcelain  such  accurate  imitations 
of  nature.  The  only  case  in  which  we  might  feel  called  upon  to  insert 
■natural  teeth  is  where  any  of  the  twelve  front  teeth  become  loosened 
by  periosteal  disease,  and  drop  from  their  sockets  while  yet  perfectly 
free  from  caries.  These  teeth  may  often  be  adjusted  to  a  plate,  so  as 
to  present  an  exceedingly  natural  appearance. 

TEETH   OF   CATTLE. 

Of  the  various  kinds  of  natural  teeth  employed  for  dental  substi- 
tutes, those  of  neat  cattle  are,  perhaps,  after  human  teeth,  the  best.  By 
slightly  altering  their  shape  they  may  be  made  to  resemble  the  incisors 
of  some  persons  ;  but  a  Configuration  similar  to  the  cuspids  cannot  be 
given  to  them,  and  in  most  cases  they  are  too  white  and  glossy.  The 
contrast,  therefore,  which  they  form  with  the  natural  organs  should  con- 
stitute, were  they  in  all  other  respects  suitable,  a  very  serious  objection 
to  their  use.  Imitation  of  nature  has  been  too  much  disregarded,  both 
by  dentists  and  patients.  Indeed,  many  of  those  who  need  artificial 
teeth  wish  to  have  them  as  white  and  brilliant  as  possible,  and  some 
practitioners  lack  either  the  decision  or  the  judgment  to  refuse  com- 
pliance with  a  practice  which  destroys  all  that  beauty  and  fitness 
which  it  is  the  aim  of  dental  aesthetics  to  cultivate. 

There  are  other  objections  to  the  use  of  these  teeth.  In  the  first 
place,  they  are  only  covered  anteriorly  with  enamel ;  in  the  second, 
their  dentinal  structure  is  less  dense  than  that  of  human  teeth,  and, 
consequently,  they  are  more  easily  acted  on  by  chemical  agents.  They 
are,  therefore,  less  durable,  seldom  lasting  more  than  from  two  to  four 
years.  Another  objection  to  their  use  is,  they  can  be  employed  in  only 
the  very  few  cases  where  short  teeth  are  required,  owing  to  the  large 
size  of  their  nerve  cavities.  It  is  seldom,  therefore,  that  they  can  be 
advantageously  used  as  substitutes  for  human  teeth. 


DENTAL   SUBSTITUTES — PORGELAIN   TEETH.  633 

IVORY    OF   THE    ELEPHANT   AND   HIPPOPOTAMUS. 

Artificial  teeth  made  from  the  ivory  of  the  tusk,  both  of  the  elephant 
and  hippopotamus,  have  been  sanctioned  by  usage  from  the  earliest 
periods  of  the  existence  of  this  branch  of  the  art.  We  must  not  hence 
conclude  that  it  has  been  approved  by  experience ;  on  the  contrary, 
of  all  the  substances  that  have  been  used  for  this  purpose  this  is  cer- 
tainly the  most  objectionable. 

The  ivory  of  the  elephant's  tusk  is  decidedly  more  permeable  than 
that  obtained  from  the  hippopotamus.  So  readily  does  it  absorb  the 
buccal  fluids  that,  in  three  or  four  hours  after  being  placed  in  the 
mouth,  it  becomes  completely  saturated  with  them.  Consequently,  it 
is  not  only  liable  to  chemical  changes,  but  the  absorbed  secretions 
undergo  decomposition;  and  when  several  such  teeth  are  worn,  they 
afifect  the  breath  to  such  a  degree  as  to  render  it  exceedingly  offensive. 
Again,  on  account  of  its  softness,  teeth  are  easily  shaped  from  it ;  but 
not  being  covered  with  enamel,  they  soon  become  dark,  and  give  to 
the  mouth  a  repulsive  appearance.  Fortunately,  however,  in  the 
Uuited  States,  elephant's  ivory  is  rarely  used,  either  as  a  base-plate 
or  for  the  teeth  themselves. 

The  ivory  of  the  tusk  of  the  hippopotamus  is  much  firmer  in  its 
texture  than  that  obtained  from  the  elephant ;  being  covered  with  a 
hard,  thick  enamel,  teeth  may  be  cut  from  it,  which,  at  first,  very 
closely  resemble  the  natural  organs.  There  is,  however,  a  peculiar 
animation  about  human  teeth,  which  those  made  from  this  substance 
do  not  possess;  moreover,  they  soon  change  their  color,  assuming  first 
a  yellow,  and  then  a  dingy  bluish  hue.  They  are,  also,  like  elephant 
ivory,  very  liable  to  decay.  We  have  in  our  possession  a  number  of 
blocks  of  this  sort,  some  of  which  are  nearly  half  destroyed.  The 
same  objection  lies  against  teeth  made  from  the  hippopotamus  ivory, 
sufficient  to  condemn  its  use.  Like  those  formed  from  elephant  ivory, 
they  give  to  the  breath  an  ofiensive  odor,  which  no  amount  of  care  or 
cleanliness  can  wholly  correct  or  prevent. 

PORCELAIN,    OR   INCORRUPTIBLE   TEETH. 

The  manufacture  of  porcelain  teeth  did  not  for  a  long  time  promise 
to  be  of  much  advantage  to  dentistry.  But  through  the  ingenuity  and 
indefatigable  exertions  of  a  few,  they  have,  within  the  last  thirty  years, 
been  brought  to  such  perfection  as  to  supersede  all  other  kinds  of 
artificial  teeth. 

The  French,  with  whom  the  invention  of  these  teeth  originated, 
encouraged  their  manufacture  by  favorable  notices;  and  the  rewards 
oflTered  by  some  of  the  learned  and  scientific  societies  of  Paris  con- 
tributed much  to  bring  it  to  perfection.     They  were  still,  however, 


G34  MECHANICS. 

deficient  in  so  many  particulars  that  they  received  the  approbation  of 
very  few  of  the  profession,  and  then  only  in  some  special  cases.  It  is 
principally  to  American  dentists  that  we  are  indebted  for  that  which 
the  French  so  long  labored  in  vain  to  accomplish. 

A  want  of  resemblance  to  the  natural  organs,  in  color,  translucency 
and  animation,  was  the  great  objection  urged  against  porcelain  teeth  ; 
and,  had  not  this  been  obviated,  it  would  have  constituted  an  insuper- 
able objection  to  their  use.  Until  1833,  all  that  were  manufactured 
had  a  dead,  opaque  appearance,  which  rendered  them  easy  of  detection, 
when  placed  beside  the  natural  teeth,  and  gave  to  the  mouth  an  un- 
natural aspect.  But  so  great  have  been  the  improvements  in  their 
manufacture,  that  few  can  now  distinguish  between  the  natural  teeth 
and  their  ai'tificial  companions,  if  well  selected  and  skillfully  applied. 

The  advantages  wdiich  mineral  teeth  possess  over  every  sort  of  animal 
substance  are  numerous.  They  can  be  more  readily  secured  to  the 
plate,  and  are  worn  with  greater  convenience.  They  do  not  absorb 
the  secretions,  and,  consequently,  when  proper  attention  is  paid  to 
their  cleanliness,  they  do  not  contaminate  the  breath,  or  become  in 
any  way  offensive.  Their  color  never  changes.  They  are  not  acted 
on  by  the  chemical  agents  found  in  the  mouth,  and  hence  the  name 
incorruptible,  which  has  been  given  them. 

Porcelain  teeth  are  divided  into  single,  sectional,  carved-block, 
continuous-gum  and  pivot-crown  teeth,  all  of  which  consist  of  a  body 
and  enamel. 

The  body  or  base  is  composed  of  silex,  feldspar  and  kaolin,  while  the 
enamel  is  principally  composed  of  feldspar,  and  is  colored  by  means  of 
metals  in  a  state  of  minute  division,  or  in  the  form  of  oxides.  The 
principal  metals  employed  for  this  purpose,  and  which  give  the  posi- 
tive tints,  are  gold,  platinum  and  titanium.  Gold,  in  a  state  of  fine 
division,  imparts  a  rose-red  tint ;  the  same  metal,  in  the  form  of  an 
oxide,  gives  a  bright  rose-red  tint.  Platinum,  in  the  form  of  sponge 
and  filings,  imparts  a  grayish-blue  tint.  Titanium,  in  the  form  of  an 
oxide,  imparts  a  bright  yellow  tint.  Other  metals,  in  the  form  of 
oxides,  are  also  employed  to  color  porcelain  teeth,  such  as  uranium, 
which  gives  a  greenish-yellow  tint ;  manganese,  a  purple  tint ;  cobalt, 
a  bright  blue  tint;  silver,  a  lemon-yellow  tint;  zinc,  also  a  lemon- 
yellow  tint ;  and  purple  of  Cassius,  a  rose-purplish  tint.  By  combining 
the  tints,  using  some  to  soften  others,  the  different  shades  of  color 
required  to  impart  character  and  a  life-like  appearance  to  artificial 
teeth  are  obtained. 

The  vast  extension  of  mechanical  practice  is  due,  more  than  to  any 
other  one  cause,  to  these  improvements  in  the  manufacture  of  porce- 
lain teeth — improvements  essentially  American,  and  so  important  as 


DENTAL  SUBSTITUTES — PORCELAIN  TEETH.       635 

fairly  to  justify  a  little  of  that  boasting  spirit  which,  transplanted 
from  the  mother  country,  has  attained  such  luxuriant  growth  in 
American  soil. 

The  beautifully  exact  imitation  of  the  varying  shades  of  the  natural 
gum,  which  as  yet  has  been  found  possible  only  in  porcelain,  would  of 
itself  give  to  this  material  a  claim  over  every  other.  All  attempts  to 
color  ivory  have  failed  to  produce  any  permanent  results.  More  recent 
experiments  in  the  several  vulcanizable  materials  have  thus  far  given 
opaque  and  lifeless  colors,  which  no  stretch  of  the  imagination  can 
compare  with  the  natural  gum,  the  nearest  approach  to  a  proper  color 
being  the  celluloid  base.  When  a  material  shall  have  been  discovered 
possessing  the  valuable  properties  of  the  vulcanite  combined  with  the 
beauty  of  a  porcelain  artificial  gum,  dental  prosthesis  will  have  nearly 
reached  perfection. 

Dr.  James  W.White,  in  a  popular  treatise  on  "The  Teeth,"  remarks : 
"  The  observant  dentist  will  take  into  the  account  complexion,  age,  sex, 
height,  the  color  of  hair  and  eyes,  and  other  characteristics  of  the  in- 
dividual, when  selecting  teeth  to  replace  lost  ones;  and  the  manu- 
facturer should  be  skilled  in  the  observance  of  the  varied  classes  of 
dentures  required.  To  inattention  in  this  direction  on  the  part  of  the 
dentist,  or  to  dictation  on  the  part  of  the  patient,  is  to  be  charged  the 
unseemly  incongruities  constantly  staring  the  observer  in  the  face,  from 
mouths  whose  lost  organs  have  been  replaced  in  disregard  of  this  uni- 
versal law.  No  matter  how  anatomically  correct,  or  how  skillfully 
adapted  for  speech  and  mastication,  an  artificial  denture  may  be,  yet 
if  it  bear  not  the  relation  demanded  by  age,  temperament,  facial  con- 
tour, etc.,  it  cannot  be  otherwise  than  that  its  artificiality  will  be 
apparent  to  every  beholder.  Artificial  teeth  should  be  natural  as  to 
shape,  color  and  vital  appearance ;  there  should  be  a  nice  blending  of 
the  colors  of  the  body  and  enamel,  not  an  abrupt  union  of  the  two  ; 
there  should  be  the  precise  amount  of  translucency,  and  the  peculiar 
texture  of  the  surface;  and  these  characteristics  should  be  maintained 
by  artificial  light  as  well  as  by  daylight;  for  many  teeth  which  in  day- 
light look  reasonably  well,  have  a  very  artificial  appearance  when 
exposed  in  the  mouth  to  an  artificial  light.  They  should  also  possess 
strength  sufficient  for  the  uses  for  which  they  are  designed.  Besides 
all  this,  there  must  be  taken  into  the  account  the  varying  forms  of  the 
jaw  or  maxillary  ridge,  so  that  the  dentist  may  be  enabled  to  select  teeth 
which  are  adapted  to  each  particular  case,  and  which  can  be  made  to 
articulate  nicely  with  each  other  or  with  the  natural  teeth,  if  there 
are  any  remaining  in  the  mouth ;  otherwise  his  best  efforts  will  not 
secure  a  good  appearance,  comfort  to  the  wearer,  or  usefulness  in 
mastication," 


636  MECHANICS. 


CHAPTER  III. 

RETENTION   OF    ARTIFICIAL   TEETH. 

TIHE  methods  of  retaining  artificial  teeth  in  place  are — first,  by 
pivoting  to  the  natural  roots ;  second,  by  attaching  to  metallic  or 
other  kind  of  base-plate,  secured  either  by,  1,  clasps;  2,  spiral  springs, 
or,  3,  atmospheric  pressure.  The  peculiar  advantages  of  each  of  these 
methods  we  shall  now  proceed  to  point  out,  and  the  cases  to  which  they 
are  particularly  applicable. 

ARTIFICIAL   TEETH   PLACED   ON   NATURAL    ROOTS. 

This  method  of  securing  artificial  teeth  was  formerly,  on  account  of 
its  simplicity,  more  extensively  practiced  than  any  other ;  and,  under 
favorable  circumstances,  it  answers  as  well  as  any  that  can  be  adopted. 
If  the  roots  on  which  they  are  placed  be  sound  and  healthy,  and  the 
back  part  of  the  jaws  supplied  with  natural  teeth,  so  as  to  prevent 
those  with  which  the  artificial  antagonize  from  striking  them  too 
directly,  they  will  subserve  the  purposes  of  the  natural  organs  more 
perfectly  than  any  other  description  of  dental  substitute,  and  can  be 
made  to  present  an  appearance  so  natural  as  to  escape  detection  upon 
the  closest  scrutiny.  If  properly  fitted  and  secured,  not  only  is  their 
connection  with  the  natural  roots  not  easily  detected,  but  they  may 
render  valuable  service  for  many  years. 

The  pivoting  of  the  lower  incisors,  from  their  small  size  and  the 
dangerous  sequelse  of  abscess,  is  frequently  an  unsatisfactory  operation. 
Many  upper  laterals  are  also  too  small  to  admit  a  pivot.  In  practice, 
the  pivoting  of  cuspids  is  seldom  called  for.  These  teeth  being  very 
persistent,  their  loss  usually  implies  that  of  many,  perhaps  all,  others, 
and  the  entire  deficiency  is  replaced  by  teeth  attached  to  a  base-plate. 

The  insertion  of  an  artificial  tooth  on  a  diseased  root,  or  on  a  root 
having  a  diseased  socket,  is  almost  always  followed  by  injurious  con- 
sequences. Filling  the  root,  together  with  proper  accompanying  treat- 
ment, will  sometimes  so  completely  arrest  disease  as  to  make  pivoting 
safe;  but  there  is  always  risk  in  these  cases.  The  morbid  action  already 
existing  in  the  root,  or  its  socket,  is  aggravated  by  the  oiDeration,  and 
often  caused  to  extend  to  the  contiguous  parts,  and  occasionally  even 
to  the  whole  mouth.  Even  in  a  healthy  root,  it  is  not  always  proper 
to  apply  a  tooth  immediately  after  having  prepared  the  root.  If  any 
irritation  is  produced  by  this  preparatory  process,  the  tooth  should  not 


RETENTION    OF    ARTIFICIAL   TEETH.  637 

be  inserted  until  it  has  wholly  subsided.  The  neglect  of  this  precau- 
tion not  unfrequeutly  gives  rise  to  inflammation  of  the  alveolo-dental 
periosteum  and  to  alveolar  abscess. 

Apart  from  the  condition  of  the  root,  the  question  of  pivoting — or 
of  a  plate  tooth  without  gum,  resembling  a  pivot  tooth — may  depend 
upon  the  adjoining  tooth  or  roots.  If,  in  any  space  to  be  supplied,  one 
root  is  absent,  all  should  be  extracted,  for  the  peculiar  beauty  of  a  pivot 
tooth  is  lost  if  its  neighbor  has  an  artificial  gum. 

Although  this  method  of  securing  artificial  teeth  has  received  the 
sanction  of  the  most  eminent  dental  practitioners,  and  is  one  of  the 
best  that  can  be  adopted  for  replacing  loss  in  the  six  upper  front 
teeth,  yet,  on  account  of  the  facility  with  which  the  operation  is 
performed,  it  is  often  resorted  to  under  the  most  unfavorable  circum- 
stances ;  in  consequence  of  which  the  method  has  been  undeservedly 
brought  into  discredit.  Apart  from  the  proneness  of  operators  to 
resort  to  this  method  when  its  adoption  is  unjustifiable,  we  may  name 
two  objections  to  the  use  of  pivot  teeth,  as  formerly  prepared  and 
inserted.  First,  the  difiiculty  of  preventing  the  presence  of  secretions 
between  the  crown  and  root,  which  make  the  breath  offensive  and 
cause  the  root  gradually  to  decay.  Secondly,  the  more  or  less  rapid 
enlargement  of  the  canal,  requiring  frequent  replacement  and  the  ulti- 
mate loss  of  the  root.  The  more  recent  methods,  however,  many  of 
which  consist  in  improvements  upon  the  older  methods,  have  obviated 
these  objections  in  a  great  measure. 

The  efforts  of  the  economy  for  the  expulsion  of  the  roots  of  the 
bicuspid  and  molar  teeth,  after  the  destruction  of  their  lining  mem- 
brane, are  rarely  exhibited  in  the  case  of  roots  of  teeth  occupying  the 
anterior  part  of  the  mouth.  This  circumstance  has  led  us  to  believe 
that  the  roots  of  these  teeth  receive  a  greater  amount  of  vitality  from 
their  investing  membrane  than  do  the  roots  of  those  situated  further 
back  in  the  mouth ;  and  that  the  amount  of  living  principle  thus 
applied  is  sufficient  to  prevent  them  from  becoming  manifestly  ob- 
noxious to  their  sockets. 

Another  explanation  assumes  the  equal  vitality  of  all  the  roots,  and 
attributes  the  persistence  of  front  i-oots,  upon  which  a  crown  has  been 
placed,  to  the  continuance  of  that  pressure  to  which  it  was  subject  so 
long  as  it  had  its  natural  crown.  It  is  asserted,  in  maintenance  of  this 
view,  that  front  roots,  left  to  themselves,  will  disappear  in  the  same 
manner  as  bicuspid  and  molar  roots,  and  that  the  latter  may  be  re- 
tained, if  the  artificial  crown  (attached  to  a  plate)  is  set  upon  them  ; 
also,  that  the  process  of  expulsion  is  analogous  to  that  by  which  a 
tooth  is  elongated  which  has  lost  its  antagonist. 

It  is  well  known  that  a  dead  root  is  always  productive  of  injury  to 


638  MECHANICS. 

the  surrounding  parts,  and  that  nature  calls  into  action  certain  agen- 
cies for  its  expulsion.  Therefore,  attaching  a  tooth  to  a  completely 
dead  root  is  manifestly  improper  ;  but  the  roots  of  the  front  teeth  are 
rarely  entirely  deprived  of  vitality,  and  hence,  after  the  destruction  of 
their  lining  membrane,  they  remain,  often,  ten,  fifteen  and  sometimes 
twenty  years,  without  very  obviously  affecting  the  adjacent  parts. 

Teeth  attached  to  a  plate  and  resting  upon  natural  roots  which  are 
in  as  healthy  a  condition  as  it  is  possible  for  such  roots  to  be,  have  all 
the  beauty  which  so  strongly  recommends  pivot  teeth.  They  are  not 
so  securely  held  in  position  ;  but  the  ability  to  remove  them  is  in  itself 
an  advantage.  This  method  is  applicable  in  many  cases  where  the 
drilling  for  a  pivot  is  impossible.  The  reader  is  referred  to  the 
chapter  describing  the  different  methods  of  pivoting  teeth. 

ARTIFICIAL   TEETH   SECURED   BY   CLASPS. 

This  method  of  securing  artificial  teeth,  first  introduced  by  the  late 
Dr.  James  Gardette,  of  Philadelphia,  is,  perhaps,  in  favorable  cases, 
one  of  the  firmest  and  most  secure  that  can  be  adopted.  By  this  means, 
the  loss  of  a  single  tooth,  or  of  several  teeth,  may  be  supplied.  A  plate 
may  be  so  fitted  to  a  space  in  the  dental  circle,  and  secured  with  clasps 
to  other  teeth,  as  to  afford  a  firm  support  to  six,  eight,  or  ten  artificial 
teeth. 

Teeth  applied  in  this  way,  when  properly  constructed,  will  last  for 
several  years,  and  sometimes  during  the  life  of  the  individual.  But  it 
is  essential  to  their  durability  that  they  should  be  correctly  arranged, 
accurately  fitted,  and  firmly  secured  to  the  plate  ;  that  the  plate  itself 
be  properly  adapted  to  the  gums,  and  the  clasps  attached  with  the 
utmost  accuracy  to  teeth  firmly  fixed  in  their  sockets. 

Gold  is  perhaps  the  best  material  that  can  be  employed  for  both 
plate  and  clasps.  Since  the  application  of  vulcanized  rubber  to  dental 
purposes,  plates  of  this  latter  material  with  gold  clasps  attached  have 
been  much  used.  When  gold  is  employed  for  the  plate  it  should  be 
from  twenty  to  twenty-one  carats  fine,  and  from  eighteen  to  nineteen 
for  the  clasps.  If  gold  of  an  inferior  quality  is  used,  it  will  be  liable 
to  be  acted  on  by  the  secretions  of  the  mouth.  Platina  pei'fectly 
resists  the  action  of  these  secretions,  and  would,  perhaps,  answer  the 
purpose  as  well  as  gold,  were  it  not  for  its  softness  and  pliancy  ;  in  full 
cases,  and  in  some  partial  cases,  the  shape  of  the  plate  may,  more  or 
less,  overcome  this  difficulty,  especially  when,  as  in  the  continuous  gum 
work,  stiffened  by  other  materials. 

The  plate  should  be  thick  enough  to  afford  the  necessary  support  to 
the  teeth ;  but  not  so  thick  as  to  be  clumsy  or  inconvenient,  from  its 
weight.   The  clasps  generally  require  to  be  about  one-third  or  one-half 


RETENTION    OF    ARTIFICIAL    TEETH.  639 

thicker  than  the  plate,  and  sometimes  double  the  thickness.  The  gold 
used  for  this  purpose  is  sometimes  pi-epared  in  the  form  of  half-round 
wire;  but  in  the  majority  of  cases  it  is  preferable  to  have  it  flat,  as 
such  clasps  afford  a  firmer  and  more  secure  support  to  artificial  teeth 
than  those  which  are  half-round ;  they  also  occasion  less  inconvenience 
to  the  patient,  and  are  productive  of  less  injury  to  the  teeth  to  which 
they  are  attached. 

Artificial  teeth,  applied  in  this  way,  may  be  worh  with  great  comfort, 
and  can  be  taken  out  and  I'eplaced  at  the  pleasure  of  the  person  wearino- 
them.  It  is  important  that  they  should  be  very  frequently  cleansed, 
to  remove  the  secretions  of  the  mouth  that  get  between  the  plate  and 
gums  and  between  the  clasps  and  teeth,  which,  becoming  vitiated,  may 
irritate  the  soft  parts  and  corrode  the  teeth  and  taint  the  breath.  This 
precaution  should,  on  no  account,  be  neglected.  Great  care,  therefore, 
should  be  taken  to  fit  the  clasps  in  such  a  manner  as  will  admit  of  the 
easy  removal  and  replacement  of  the  piece,  and  also,  that  they  may  not 
exert  any  undue  pressure  upon  the  teeth  to  which  they  are  applied. 

If  the  clasp,  in  consequence  of  inaccurate  adjustment,  strains  the 
position  of  the  tooth  in  its  socket,  it  may  excite  inflammation  in  the 
alveolo-dental  periosteum,  and  the  gradual  destruction  of  the  socket 
will  follow  as  a  natural  consequence.  Also,  if  the  clasp  press  too  closely 
upon  the  neck  of  the  tooth,  it  may  develop  a  morbid  sensibility  in  the 
cementum,  causing  great  annoyance,  and  possibly  exciting  inflamma- 
tion and  alveolar  absorption  or  loosening  of  the  tooth. 

Several  .years  since.  Dr.  Goodall  obtained  a  patent  for  a  method  of 
retaining  partial  sets  of  artificial  teeth  by  elastic  or  spring  plates  of 
vulcanized  rubber,  the  utility  of  which,  indiscriminately  applied,  as 
well  as  the  validity  of  the  patent,  some  are  disposed  to  doubt,  contend- 
ing that  these  plates  differ  but  little  from  metallic  ones  formerly  in 
use,  constructed  in  the  same  manner,  and  described  as  partial  or  stay- 
clasps. 

This  form  of  clasp,  instead  of  embracing  the  natural  tooth,  simply 
presses  against  the  inner  surface  of  the  contracted  portion  of  the  crown 
near  the  gum,  with  a  force  which  is  sufficient  to  keep  the  substitute  in 
place. 

Prof.  Austen's  method  of  taking  plaster  impressions  in  partial  cases 
was  designed  by  him,  in  1858,  with  special  reference  to  obtaining  an 
accurate  copy  of  the  inner  surface  of  bicuspids  and  first  molars.  Accu- 
rate fitting  of  the  vulcanite  plate  against  one  or  two  such  teeth  on  each 
side  prevents  lateral  motion,  and  gives  great  stability  to  the  piece.  It 
takes  the  place  of  the  vacuum  cavity  with  much  better  results  ;  in  fact, 
he  regards  this  form  of  stay-plate  essential  to  every  partial  piece  not 
clasped,  whilst  he  regards  the  cavity  worse  than  useless. 


640  MECHANICS. 

The  reader  is  referred  to  the  chapter  describing  the  method  of  re- 
tention by  clasps. 

ARTIFICIAL   TEETH   WITH   SPIRAL   SPRINGS. 

The  difference  between  the  method  of  applying  artificial  teeth  last 
noticed,  and  the  one  now  to  be  considered,  consists  in  the  manner  of  con- 
fining them  in  the  mouth.  The  former  is  applicable  in  cases  where 
there  are  other  teeth  in  the  mouth  to  which  clasps  may  be  applied  ; 
the  latter  is  designed  for  confining  a  double  set ;  more  rarely  a  single 
set  or  part  of  a  set.  When  plates  with  spiral  springs  are  used,  the 
teeth  are  attached  to  them  in  the  same  manner  as  when  clasps  are  em- 
ployed ;  but  instead  of  being  fastened  in  the  mouth  to  other  teeth,  they 
are  kept  in  place  by  means  of  the  spiral  springs,  lying  one  on  each  side 
of  the  artificial  dentures  between  them  and  the  cheeks,  passing  from 
the  upper  piece  to  the  lower. 

Sjiiral  springs  were  formerly  much  used,  and  although  various  other 
kinds  of  springs  have  been  used,  none  seem  to  answer  the  purpose  as 
well  as  these.  When  they  are  of  the  right  size,  and  attached  in  a 
proper  manner,  they  afford  a  very  sure  and  convenient  support.  They 
exert  a  constant  pressure  upon  the  artificial  pieces,  whether  the  mouth 
is  opened  or  closed.  They  do  not  interfere  with  the  motions  of  the  javv, 
and,  although  they  may  at  first  seem  awkward,  a  person  will  soon 
become  so  accustomed  to  them  as  to  be  almost  unconscious  of  their 
presence.  They  are,  however,  liable  to  derangement  from  accident ; 
they  make  the  piece  awkward  to  handle  in  the  necessary  daily  cleans- 
ing;  they  retain  the  secretions  offensively;  and  not  unfrequently  are 
a  source  of  much  irritation  to  the  cheek. 

It  is  therefore  a  subject  of  congratulation  that  successive  improve- 
ments in  the  process  of  adapting  the  plate  to  the  mouth  have  gradually 
lessened  the  number  of  cases  in  which  spiral  springs  are  thought  neces- 
sary. It  is  now  rare  to  meet  with  a  case  in  which  they  are  absolutely 
essential  for  the  permanent  retention  of  the  piece.  Occasional  use  is 
made  of  them  for  the  temporary  retention  of  a  piece  made  soon  after 
extraction,  in  which  the  plate  is  designedly  made  more  even  than  the 
irregular  alveolar  border  ;  which  plate  cannot,  of  course,  fit  the  mouth, 
until  the  inequalities  of  the  gum  have  yielded  to  the  pressure  of  the 
plate. 

TEETH   RETAINED   BY   ATMOSPHERIC   PRESSURE. 

The  method  of  confining  artificial  teeth  in  the  mouth,  last  described, 
is  often  inapplicable,  inefficient  and  troublesome,  especially  for  the 
upper  jaw  ;  in  such  cases,  the  atmospheric  pressure,  or  suction  method, 
is  very  valuable.  It  was,  for  a  long  time,  thought  to  be  applicable 
only  to  an  entire  upper  set,  because  it  was  supposed  that  a  plate  suf- 


RETENTION   OF   ARTIFICIAL,   TEETH.  641 

ficiently  large  to  afford  the  necessary  amount  of  surface  for  the  atmos- 
phere to  act  upon  could  not  be  furnished  by  a  piece  containing  a  smaller 
number  of  teeth.  Experience,  however,  has  proved  this  opinion  to  be 
incorrect.  A  single  tooth  may  be  mounted  upon  a  plate  presenting  a 
surface  large  enough  for  the  atmosphere  to  act  upon  for  its  retention 
in  the  mouth ;  but  when  only  a  partial  upper  set  is  required,  it  is  often 
more  advisable  to  secure  the  piece  by  means  of  clasps.  For  a  like 
reason,  it  was  thought  that  the  narrowness  of  the  inferior  alveolar 
ridge  would  preclude  the  application  of  a  plate  to  it  upon  this  principle, 
and  in  this  opinion  the  author  once  coincided  ;  but  he  has  succeeded  so 
perfectly  in  confining  lower  pieces  by  this  means,  that  he  now  never 
finds  it  necessary  to  employ  spiral  springs  for  their  retention. 

The  principle  upon  which  this  plan  is  founded  may  be  simply  illus- 
trated by  taking  two  small  blocks  of  marble  or  glass,  the  flat  surfaces 
of  which  accurately  fit  each  other.  If  now  the  air  between  them  is 
replaced  by  water,  the  atmospheric  pressure  upon  their  external  sur- 
faces will  enable  a  person  to  raise  the  under  block  by  lifting  the  upper. 
Upon  the  same  principle,  a  gold  plate,  or  any  other  substance  imper- 
vious to  the  atmosphere,  and  perfectly  adapted  to  the  gums,  may  be 
made  to  adhere  to  them. 

The  firmness  of  the  adhesion  of  the  plate  or  base  to  the  gums  depends 
on  the  accuracy  of  its  adaptation.  If  this  is  perfect,  it  will  adhere 
with  great  tenacity ;  but  if  the  plate  is  badly  fitted,  or  becomes  warped 
in  soldering  on  the  teeth,  its  retention  will  often  be  attended  with 
difficulty.  It  is  also  important  that  the  teeth  should  be  so  arranged 
and  antagonized,  that  they  shall  strike  those  in  the  other  jaw  on 
both  sides  at  the  same  instant.  This  is  a  matter  that  should  never 
be  overlooked,  for  if  they  meet  on  one  side  before  they  come  together 
on  the  other,  the  part  of  the  plate  or  base  not  pressed  upon  may 
be  detached,  and  by  admitting  the  air  between  it  and  the  gums,  cause 
it  to  drop. 

Since,  in  the  act  of  mastication,  pressure  is  made  on  one  side,  with 
no  counter-pressure  on  the  other,  this  inequality  will  not  necessarily 
detach  a  well-made  piece.  But  when  the  upper  molars  are  set  so  far 
from  the  median  line  of  the  mouth  that  the  line  of  pressure  falls  outside 
the  alveolar  ridge,  it  is  difficult  to  retain  the  best-fitting  piece  in  place 
during  mastication. 

It  is  also  of  the  utmost  importance  that,  by  proper  selection  of  the 
impression  material,  and  judicious  management  of  subsequent  pro- 
cesses, the  plate  should  bear  upon  the  ridge  more  than  upon  the  palate. 
In  doing  this,  however,  no  more  space  should  be  left  than  a  few  days 
wear  will  obliterate,  giving  absolute  contact  over  the  entire  surface. 
For  there  is  no  kind  of  space,  cavity,  or  chamber  which  gives  so  com- 
41 


042  MECHANICS. 

plete  a  vacuum  as  contact,  or  which  secures  such  permanently  useful 
adhesion  of  the  plate. 

The  application  of  artificial  teeth  on  this  principle  has  been  prac- 
ticed for  a  long  time.  Its  practicability  was  first  discovered  by  the  late 
Mr.  James  Gardette,  of  Philadelphia.  But  the  plates  formerly  used 
were  ivory  instead  of  gold,  and  could  seldom  be  fitted  with  sufficient 
accuracy  to  the  mouth  to  exclude  the  air ;  so  that,  in  fact,  it  could 
hardly  be  said  that  they  were  retained  by  its  pressure  ;  except  in  that 
class  of  cases  in  which  the  mouth,  by  virtue  of  a  soft  membrane,  has 
power  to  adapt  itself  to  the  plate.  Unless  fitted  in  the  most  perfect 
manner,  the  piece  is  constantly  liable  to  drop ;  and  the  amount  of  sub- 
stance necessary  to  leave  in  an  ivory  substitute  renders  it  so  awkward 
and  clumsy  that  a  set  of  teeth  mounted  upon  a  base  of  this  material 
can  seldom  be  worn  with  much  comfort  or  satisfaction. 

The  firmness  with  which  teeth  applied  upon  this  principle  can  be 
made  to  adhere  to  the  gums,  and  the  facility  with  which  they  can  be 
removed  and  replaced,  renders  them,  in  many  respects,  more  desirable 
than  those  fixed  in  the  mouth  with  clasps.  But  unless  judgment  and 
proper  skill  are  exercised  in  the  construction  of  the  work,  a  total 
failure  may  be  expected,  or,  at  least,  the  piece  will  never  be  worn  with 
satisfaction  and  advantage. 

There  were  few  writers,  at  the  time  of  the  publication  of  the  first 
edition  of  this  work,  who  had  even  adverted  to  this  mode  of  applying 
artificial  teeth.  Drs.  L.  8.  Parmly  and  Koecker  had  each  bestowed 
on  it  a  passing  notice.  The  former,  in  alluding  to  the  subject,  thus 
remarks  :  "  Where  the  teeth  are  mostly  gone  in  both  or  in  either  of 
the  jaws,  the  method  is  to  form  an  artificial  set  by  first  taking  a  mould 
of  the  risings  and  depressions  of  every  point  along  the  surface  of  the 
jaws,  and  then  making  a  corresponding  artificial  socket  for  the  whole. 
If  this  be  accurately  fitted,  it  will,  in  most  cases,  retain  itself  sufficiently 
firm,  by  its  adhesion  to  the  gums,  for  every  purpose  of  speech  and 
mastication." 

Modifications  of  the  atmospheric  pressure  principle  have  been  made 
since  1845,  by  constructing  the  plate  with  an  air  chamber  or  cavity,  so 
that  when  the  air  is  exhausted  from  between  it  and  the  parts  against 
which  it  is  placed,  a  more  or  less  complete  vacuum  is  formed,  causing 
it  to  adhere  when  first  introduced  with  greater  tenacity  to  the  gums 
than  a  base  fitted  without  such  cavity.  This  modification  might  be 
termed  an  improvement,  were  it  not  that  its  introduction  has  become 
so  unnecessarily  general,  has  so  often  induced  a  diseased  condition  of 
the  mucous  membrane,  and  has  led  to  a  slovenly,  careless  method  of 
swaging  and  fitting  plates.  For  these  and  some  other  reasons.  Prof. 
Austen  regards  its  introduction  as  a  positive  detriment,  at  the  same 


PREPARATORY  TREATMENT  OF  THE  MOUTH.       643 

time  that  he  acknowledges  its  occasional  utility.  He  argues  that 
theory  and  practice  alike  condemn  the  use  of  a  cavity  for  the  perma- 
nent retention  of  any  piece ;  and  suggests  for  its  temporary  retention, 
whilst  the  work  is  going  through  its  stage  of  adaptation,  some  other 
plan  than  this  permanent  disfigurement.  The  so-called  vacuum  cavity 
can,  at  best,  be  only  partially  a  vacuum,  hence  cannot  give  the  amount 
of  atmospheric  pressure  that  perfect  contact  will.  So  long  as  it  acts  in 
the  retention  of  a  piece,  it  necessarily  draws  the  yielding  membrane 
into  the  space,  and  must  ultimately  fill  it.  When  this  is  done,  the 
piece  is  evidently  retained  by  the  "  vacuum  of  contact."  If,  in  any 
case,  the  mouth  does  not  show  the  size  and  depth  of  the  cavity  im- 
printed on  the  palate,  it  proves  that  the  vacuum  force  is  not  exerted, 
and  that  the  piece  is  retained  by  contact  of  the  parts  around  the 
cavity.  In  these  cases,  of  constant  occurrence,  the  cavity  diminishes 
the  adhesion  of  the  plate,  and  can  only  be  of  service  where  it  helps  to 
remove  pressure  from  a  hard  palate.  But  as  this  can  be  done  in  a 
better  way,  it  is  no  argument  in  favor  of  the  cavity. 

The  only  cases  in  which  this  chamber  is  permanently  useful  are 
very  flat  mouths  with  scarcely  any  perceptible  ridge.  A  sharply  de- 
fined cavity,  varying  in  depth  from  one-half  to  one  line,  according  to 
the  softness  of  the  membrane,  when  filled  by  this  membrane,  tends  to 
prevent  that  lateral  motion  of  the  piece  so  troublesome  in  such  cases. 

Partial  pieces  not  retained  by  clasps,  or  the  lateral  pressure  of  stays, 
or  their  closeness  of  adaptation,  are  never  permanently  improved  by 
the  cavity-.  Even  in  pieces  made  soon  after  extraction  (so  unfortu- 
nately named  temporary  sets),  the  temporary  action  of  the  cavity  is  of 
very  questionable  utility  (See  Chapter  XIII). 


CHAPTER  IV. 

PREPARATORY  TREATMENT  OP  THE  MOUTH. 

THE  condition  of  the  mouth  is  not  sufficiently  regarded  in  the 
application  of  artificial  teeth,  and  to  the  neglect  of  this  the  evil 
effects  that  so  often  result  from  their  use  are  frequently  attributable. 
An  artificial  appliance,  no  matter  how  correct  it  may  be  in  its  con- 
struction and  in  the  mode  of  its  application,  cannot  be  worn  with 
impunity  in  a  diseased  mouth.  Of  this  fact,  every  day's  experience 
furnishes  the  most  abundant  proof  Yet  there  are  men  in  the  profes- 
sion so  utterly  regardless  of  their  own  reputation,  and  of  the  conse- 


644  MECHANICS. 

quences  to  their  patients,  as  wholly  to  disregard  the  condition  of  the 
mouth,  and  are  in  the  constant  habit  of  applying  artificial  teeth  upon 
diseased  roots  and  gums,  or  before  the  curative  process  after  the 
extraction  of  the  natural  teeth  is  half  completed. 

The  dentist,  it  is  true,,  may  not  always  be  to  blame  for  omitting  to 
employ  the  means  necessary  for  the  restoration  of  the  mouth  to  health. 
The  fault  is  often  with  the  patient.  There  are  many  who,  after  being 
fully  informed  of  the  evil  effects  which  must  of  necessity  result  from 
such  injudicious  practice,  still  insist  on  its  adoption.  But  the  dentist, 
in  such  cases,  does  wrong  to  yield  his  better  informed  judgment  to  the 
caprice  or  timidity  of  his  patient,  knowing,  as  he  should,  the  lasting, 
pernicious  consequences  that  must  result  from  doing  so.  If  he  is  not 
permitted  to  carry  out  such  plan  of  treatment  as  may  be  necessary  to 
put  the  mouth  of  his  patient  in  a  healthy  condition  previously  to  the 
application  of  artificial  teeth,  he  should  refuse  to  render  his  services. 
No  professional  man  can  be  permitted  to  plead  in  excuse  for  any  pro- 
fessional error  that  his  patient  over-persuaded  him.  No  community 
will  accept  such  excuse,  or  hold  the  patient  in  any  degree  responsible 
for  the  consequences. 

Dr.  Koecker,  in  treating  upon  this  subject  says  :  "  There  is,  perhaps, 
not  one  case  in  a  hundred,  requiring  artificial  teeth,  in  which  the  other 
teeth  are  not  more  or  less  diseased,  and  the  gums  and  alveoli,  also, 
either  primarily  or  secondarily  affected.  The  mechanical  and  chem- 
ical bearing  of  the  artificial  teeth,  even  if  well  contrived  and  inserted 
upon  such  diseased  structures,  naturally  becomes  an  additional  aggra- 
vating cause  of  disease  in  parts  already  in  a  sufficient  state  of  excite- 
ment; if,  however,  they  are  not  well  constructed,  and  are  inserted 
with  undue  means  or  force,  or  held  by  too  great  or  undue  pressure,  or 
by  ligatures  or  other  pernicious  means  for  their  attachment,  the  morbid 
effects  are  still  more  aggravated,  and  a  general  state  of  inflammation 
in  the  gums  and  sockets,  and  particularly  in  the  periosteum,  very 
rapidly  follows.  The  patient,  moreover,'finds  it  impossible  to  preserve 
the  cleanliness  of  his  mouth ;  and  his  natural  teeth,  as  well  as  the  arti- 
ficial apparatus,  in  combination  with  the  diseases  of  the  structures, 
become  a  source  of  pain  and  trouble ;  and  the  whole  mouth  is  rendered 
highly  offensive  and  disgusting  to  the  patient  himself  as  well  as  to 
others."  * 

The  first  thing,  then,  claiming  the  attention  of  the  dentist,  when 
applied  to  for  artificial  teeth,  is  to  ascertain  the  condition  of  the  gums, 
and  of  such  teeth  as  may  be  remaining  in  the  mouth.  If  either  or 
both  are  diseased,  he  should  at  once  institute  such  treatment  as  the 
circumstances  of  the  case  may  indicate  ;  but  as  this  has  been  described 
*  Koecker' s  Essay  on  Artificial  Teeth,  pp.  27,  28. 


PREPAEATORY  TREATMENT  OF  THE  MOUTH.       645 

in  a  preceding  chapter,  the  reader  is  referred,  for  directions  upon  the 
subject  to  what  is  there  said.  Without,  however,  repeating  previous 
medical  and  surgical  directions,  a  few  brief  hints  are  necessary  as  to 
what  teeth  or  roots  should  be  extracted  and  what  allowed  to  remain 
in  preparation  for  a  dental  plate. 

All  incurably  diseased  roots  or  teeth  should  be  removed,  also  all 
roots  of  molars  in  either  jaw,  and  all  roots,  without  exception,  in  the 
lower  jaw.  Firm  and  healthy  roots  of  bicuspids  may  sometimes  be 
retained,  the  plate  coming  to  the  inner  edge  of  such  root  and  the  arti- 
ficial crown  resting  upon  it.  It  is  desirable  to  retain  upper  incisors  or 
canine  roots,  unless  an  adjacent  tooth  has  lost  its  root  or  is  incurably 
diseased.  These  cases  of  retention  of  roots  presuppose  the  presence 
of  other  teeth;  for  when  only  roots  remain  in  the  jaw,  they  must 
be  extracted.  Also,  they  must  be  removed,  however  sound,  if  they  are 
sources  of  irritation  in,  or  are  partially  covered  with,  mucous  membrane. 

Very  loose  teeth, although  not  carious,  should  be  extracted;  but  teeth 
in  which  caries  or  abscess  can  be  permanently  cured  rank  as  sound 
teeth.  All  sound  teeth  must  be  retained,  if  there  are  more  than  four 
in  either  jaw,  unless  some  peculiar  circumstances  justify  their  removal. 
Cases  of  this  kind  are  so  varying  that  no  fixed  rule  can  be  laid  down ; 
but  a  few  cases  may  be  given  in  illustration  of  the  principles  that 
should  guide  the  practitioner. 

Two,  three,  or  four  molars  alone  remaining  should  be  retained,  espe- 
cially if  they  have  antagonists.  They  do  not  complicate  the  construc- 
tion of  the  piece  or  interfere  with  its  utility ;  but  they  should  not  be 
clasped,  since  the  whole  weight  being  in  front  of  the  clasp  brings  too 
much  strain  on  the  teeth.  Two,  three,  or  four  incisors  alone  remaining 
cannot  be  extracted  except  by  request  of  the  patient;  for  although 
they  complicate  the  construction,  and  may  interfere  somewhat  with  the 
strength  and  beauty  of  the  work,  they  may  be  too  valuable  to  justify 
their  loss.  The  cuspids  must  be  retained,  if  sound,  not  displaced,  and 
free  from  alveolar  absorptiori,  although  their  retention  may  greatly 
complicate  the  work. 

In  cases  of  protrusion  of  the  lower  jaw,  it  may  be  advisable  to 
extract  the  five  front  teeth  in  either  jaw,  wdiere  these  are  the  sole 
remaining  ones,  with  a  view  to  correct,  in  part,  the  protrusion  of  the 
mouth.  But  this  cannot  be  done  without  fullest  consent  of  the  patient; 
even  then  is  scarcely  advisable  unless  these  teeth  are  frail  in  texture* 
or  their  position  amounts  to  deformity. 

In  all  cases  it  should  be  the  rule  never  to  sacrifice  a  sound  tooth  for 
the  purpose  of  replacing  an  artificial  one,  unless  the  benefit  of  the 
exchange  is  so  undoubted  as  to  be  recognized  by  both  patient  and 
operator. 


646  MECHANICS. 

Wheu  artificial  teeth  are  to  be  secured  in  the  mouth  in  any  other 
way  than  by  pivoting  upon  the  roots,  if  the  patient  desires  but  one 
piece,  sufRcient  time  should  elapse,  before  its  insertion,  for  the  com- 
pletion of  those  changes  in  the  alveolar  ridge  that  follow  extraction. 

It  is  often  necessary  to  wait  from  eight  to  fifteen  months,  after  the 
removal  of  the  natural  teeth,  for  the  completion  of  these  changes. 
Comparatively  few  persons,  however,  are  willing  to  remain  for  so  long 
a  time  without  teeth ;  nor,  on  many  accounts,  is  it  desirable  that  they 
should.  In  this  long  interval  the  lips  lose  somewhat  their  natural  ex- 
pression, and  the  under  jaw  forgets  its  natural  motion,  and  inclines  to 
project.  The  artificial  piece  or  pieces  feel  more  awkward  and  unman- 
ageable than  if  inserted  at  once ;  they  also  interfere  more  with  the 
articulation  and  motions  of  the  tongue,  which  have  become  accustomed 
to  the  absence  of  the  teeth. 

Hence  the  insertion  of  artificial  pieces  may  become  advisable  very 
soon  after  extraction — the  interval  varying  from  hours  or  days  to 
weeks  or  months.  In  some  of  these  cases  the  piece  will  have  to  be 
remodeled  at  short  intervals;  in  other  cases  the  piece,  as  first  made, 
continues  to  be  worn  for  many  years  with  much  comfort.  It  is  not 
easy  to  explain  these  differences.  Much  depends  upon  the  nature  of 
the  mucous  and  submucous  tissues,  whether  hard  or  soft ;  and  much 
also  upon  the  manner  in  which  the  alveolar  ridge  changes.  It  may 
take  place  rapidly,  and  with  slight  regard  to  the  shape  of  the  plate ; 
in  which  case  the  patient  has  to  use  much  tact  in  retaining  the  piece 
in  place.  Or  it  may  take  place  slowly,  following,  as  it  is  apt  more  or 
less  to  do,  the  shape  of  the  plate ;  in  which  case  it  may  be  worn  with 
some  comfort,  or  even  with  great  satisfaction,  for  a  long  time. 

A  plate  made  immediately  after  extraction  should  not  fit  the  ridge 
exactly  ;  but  allowance  should  be  made  for  the  rapid  absorption  of  the 
prominent  edges  of  the  alveoli.  Some  practitioners  advise  the  antici- 
pation of  this  process  by  "  paring  down  "  the  alveolar  ridge.  This 
"  bold  surgery  "  has  its  advantages  and  its  advocates.  The  operators 
say  it  does  not  hurt  much ;  but  the  testimony  of  the  patient  on  this 
point  is  more  trustworthy. 

The  almost  universal  use  of  the  term  "  temporary,"  applied  to  a 
piece  made  within  six  months  after  extraction  of  the  teeth,  is  much 
to  be  regretted.  It  tempts  the  dentist  to  a  slovenly  style  of  half-made 
work,  good  enough,  in  his  estimation,  for  what  is  so  soon  to  be  replaced. 
It  also  renders  the  patient  reluctant  to  make  proper  compensation  for 
the  time  and  skill  employed.  Both  feelings  react,  until  it  has  become 
a  notorious  fact  that  much  low-priced  work  passes  from  the  hands  of 
skillful  mechanicians  Avhich  they  would  indignantly  disown  as  speci- 
mens of  their  workmanship. 


NATURAL  ROOT   AND   ARTIFICIAL   CROWN.  647 

Yet  they  are  specimens  which  a  community  is  right  in  judging  by. 
It  is  unfortunate  for  dentistry  that  so  many,  using  their  best  efforts, 
accomplish  poor  results.  But  it  is  infinitely  more  damaging  to  its 
character,  that  a  skilled  operator  should,  under  any  pretext,  permit 
himself  to  be  false  to  th£  trust  reposed  in  his  professional  capacity.  A 
chain  is  judged  by  its  weakest  link,  and  a  workman's  reputation  turns 
on  his  poorest  work.  This  seemingly  harsh  verdict  is  a  just  one,  because 
necessary  to  keep  the  majority  of  men  to  the  full  measure  of  their 
ability. 

Let  the  work  be  done  as  if  it  never  was  to  be  done  again.  Many 
circumstances  may  prevent  the  return  of  the  patient ;  it  also  frequently 
happens  that  no  necessity  is  felt,  especially  if  properly  done,  for  the 
renewal  of  the  piece.  If  the  patient  understands  that  the  necessity  of 
renewal  is  not  in  the  work  itself,  but  arises  from  unavoidable  changes 
in  the  mouth,  there  will  be  no  difficulty  about  proper  compensation. 
But  if  the  absurd  practice  of  half-price  at  one  time  for  what  receives 
full  price  at  another  must  be  maintained,  then,  by  all  means,  let  the 
second  piece  be  the  half-paid  one. 

The  point,  however,  involves  far  higher  questions  than  the  one  of 
fees.  No  dentist  who  properly  respects  himself  or  his  profession  will, 
either  on  the  score  of  insufficient  pay  or  temporary  use,  permit  himself 
to  issue  two  grades  of  work.  Like  Pharaoh's  lean  kine,  the  low  grade 
will,  slowly  perhaps,  but  inevitably,  destroy  the  high  grade.  The  only 
safe  rule  is  "  excelsior  "  in  every  case. 


CHAPTER  V. 


PREPARATION   OF   A   NATURAL   ROOT   AND    ATTACHMENT   OF   AN 
ARTIFICIAL   CROWN. 

PREVIOUS  to  the  preparation  of  a  natural  root  for  the  reception 
of  an  artificial  crown,  the  remaining  teeth  and  gums,  if  diseased, 
should  be  restored  to  health.  This  done,  such  portion  of  the  crown 
as  may  not  have  been  previously  destroyed  by  caries  should  be  removed. 
The  usual  method  of  performing  this  part  of  the  operation,  when 
much  of  the  crown  remains,  consists  in  cutting  the  tooth  about  three- 
fourths  off,  with  a  file,  a  very  fine  saw  (Fig.  419),  or  corundum  disk, 

Fig.  419. 


648 


MECHANICS. 


and  then  removing  it  with  a  pair  of  excising  forceps.  But  the  forceps 
should  not  be  applied  until  the  tooth  has  been  cut  with  a  file  on  every 
side,  nearly  to  the  pulp  cavity,  and  even  then  great  care  is  necessary 
to  prevent  jarring,  or  otherwise  injuring  the  root.  When  too  large  a 
portion  of  the  crown  is  clipped  off  suddenly  with  excising  forceps,  the 
concussion  is  often  so  great  as  to  excite  inflammation  in  the  socket  of 
the  tooth,  and  sometimes  to  fracture  the  root. 

When  excising  forceps  are  used  in  this  way,  they  should  be  strong, 
so  as  not  to  spring  under  the  pressure  of  the  hand,  with  cutting  edges 

Fig.  420. 


about  an  eighth  of  an  inch  wide  (Fig.  420).  But  we  should  prefer, 
where  a  large  part  of  the  crown  is  left,  to  remove  it  entirely  with  the 
fine  saw,  or  separating  file,  or  corundum  disk.  Where  there  is  only  a 
jagged  remnant  of  the  crown  left,  it  should  be  gradually  cut  away  by 
a  pair  of  cutting  forceps  made  as  light  as  possible,  with  a  spring 
between  the  blades  of  the  handle,  to  keep  them  apart.  The  cutting 
edges  may  be  shaped  as  in  the  ordinary  excising  forceps  (Fig.  420),  or 
somewhat  like  the  beaks  of  Parmly's  duck-bill  root  forceps, represented 
in  Fig.  421. 

Fig.  421. 


After  the  removal  of  the  remaining  portion  of  the  crown,  the  pulp, 
if  still  alive,  should  be  immediately  destroyed,  by  introducing  a  silver 
or  unterapered  steel  wire,  or  barbed  broach,  up  to  the  extremity  of  the 
root,  by  giving  it,  at  the  same  time,  a  quick  rotary  motion.  It  is  im- 
portant that  the  instrument  used  for  this  purpose  should  be  soft  and 
yielding,  otherwise  any  sudden  motion  of  the  patient  might  break  it 
off  in  the  tooth.  Its  extremity  should  also  be  barbed  or  bent  so  as  to 
entangle  and  drag  out  the  pulp  when  withdrawn. 

The  pulp  having  been  destroyed,  the  remainder  of  the  operation  will 
be  painless.  The  root  may  now  be  filed  or  ground  off,  a  little  above 
the  free  edge  of  the  gum,  with  an  oval  or  half-round  file,  or  a  corundum 
wheel  with  a  round  edge.     The  file  should  be  new  and  sharp,  so  as  to 


NATURAL,   ROOT   AND   ARTIFICIAL   CROWN. 


649 


cut  rapidly,  but  not  too  coarse,  lest  it  jar  the  root  too  much.  It  must 
be  kept  cold  and  clean  by  frequently  dipping  in  water ;  also  the 
corundum  wheel.  Fig.  422  represents  pivot  files  and  wheels.  The 
exposed  extremity  of  the  root,  after 
having  been  thus  filed,  should  present 
a  slightly  arched  appearance,  corres- 
ponding with  the  festooned  shape  of  the 
anterior  margin  of  the  gum. 

After  having  completed  this  part  of 
the  operation,  the  natural  canal  in  the 
root  should  be  slightly  enlarged  with  a 
burr-drill,  or  a  broach  prepared  for  the 
purpose.  A  slightly  projecting  point 
on  the  end  of  the  drill  will  serve,  by 
entering  the  canal,  to  guide  the  instru- 
ment, which  must  be  held  steadily  in 
one  direction.  The  canal  thus  formed 
in  the  root  for  the  pivot  should  never 
exceed  the  sixteenth  part  of  an  inch 
or  a  line  in  diameter,  and  a  quarter  or 
three-eighths  of  an  inch  in  length. 

If,  from  any  peculiar  constitutional 
susceptibility,  there  is  reason  to  appre- 
hend inflammation  of  the  alveolo-dental 
membrane,  the  insertion  of  the  tooth 
may  be  delayed  a  few  days,  for  the  sub- 
sidence of  any  irritation  which  may 
have  been  occasioned  by  the  prepara- 
tion of  the  root.  It  will  be  prudent  to 
do  this  in  all  cases,  although  it  rarely 
happens  that  the  operation  is  followed 
by  any  unpleasant  efiects,  unless  the  root 
has  previously  lost  its  vitality  by  the 
spontaneous  disorganization  of  the  ner- 
vous pulp.  In  this  case,  an  outlet  is 
sometimes  made  by  cutting  a  groove  on 
the  side  of  the  pivot,  or  in  some  other 
way,  for  the  escape  of  any  matter  which 
may  form  at  the  apex  of  the  root ;  but 
it  is  far  better,  in  such  cases,  to  extract 
the  root,  unless  the  discharge  can  be  permanently  arrested.  Dr. 
Maynard  believes  that  the  irritation  in  most  cases  arises  from  an 
accumulation  of  acrid  matter  in  the  upper  part  of  the  root ;   by  re- 


650  MECHANICS. 

moving  which,  and  by  filling  the  natural  canal  above  the  terminus 
of  the  pivot,  up  to  the  extremity,  it  may  generally  be  prevented. 
This  should  always  be  done  before  deciding  to  extract  the  root. 

After  having  prepared  the  root,  au  artificial  crown,  of  the  right 
shape,  color  and  size,  is  accurately  fitted  to  it.  It  should  touch  every 
part  of  the  filed  extremity  of  the  root,  and  be  made  to  rest  firmly  upon 
it,  to  give  security  of  support,  and  to  exclude  food  and  other  substances 
which  by  their  decay  will  give  rise  to  unpleasant  odors.  Care  must 
also  be  used  to  have  the  tooth  placed  in  exact  line  with  the  other  teeth, 
not  inclining  unnaturally  to  either  side,  and  not  so  long  as  to  touch 
the  lower  teeth  when  the  mouth  is  closed.  To  fit  the  crown  accurately 
is  often  a  tedious  process,  and  wearies  the  patient.  To  avoid  this,  an 
impression  of  the  space  may  be  taken,  and  the  crown  adapted  to  the 
model,  which  should  be  hardened  by  varnish  or  soluble  glass. 

The  canal  in  the  root,  and  that  in  the  artificial  crown,  should  be 
directly  opposite  to  each  other.     When  the  crown  of  a  natural  tooth 
is  used,  it  can  be  adapted  to  the  root  by  the  use  of  the  file ;  the  proper 
place  for  the  pivot  is  indicated  by  the  pulp  cavity,  but  in  porcelain 
teeth  the  hole  is  not  always  in  the  centre. 
biG.  423.  jjj  selecting  a  suitable  artificial  pivot  tooth, 

it  is  often  difficult  to  find  the  several  conditions 
of  length,  width,  color,  and  position  of  pivot 
hole  just  as  required.  The  last  two  cannot  be 
changed,  but  the  first  two  may  often  be  modi- 
fied by  the  corundum  wheel.  If  the  color 
cannot  be  exactly  matched,  it  is  perhaps  better 
to  select  one  a  shade  darker,  rather  than  lighter. 
For  grinding  the  edge,  sides  or  base  of  the 
tooth,  any  of  the  hand  or  office  foot-lathes  in 
use  will  answer  very  well  (Figs.  423  and  424). 
The  artificial  crown  may  be  secured  to  the  root  by  means  of  a  pivot 
made  of  wood  or  metal ;  when  the  latter  is  employed,  gold,  platinum, 
or  platinum  and  iridium,  is  to  be  preferred,  inasmuch  as  silver  or  any 
baser  metal  is  liable  to  be  oxidized  by  the  fluids  of  the  mouth.  If  wood 
is  used,  it  should  be  of  the  best  quality  of  well-seasoned,  young,  white 
hickory,  or  locust,  as  these  possess  greater  strength  and  hardness  than 
any  others  that  can  be  used  for  the  purpose.  After  being  reduced  nearly 
to  the  size  of  the  canal  in  the  artificial  tooth,  it  should  be  forced  through 
a  smooth  hole,  of  the  proper  size,  in  a  piece  of  ivory,  bone,  steel,  or  some 
other  hard  substance,  for  the  purpose  of  compressing  its  fibres  as  closely 
together  as  possible.  Thus  prepared,  one  end  is  forced  into  the  cavity  in 
the  artificial  crown,  and  the  projecting  part  cut  off  about  a  quarter  or 
three-eighths  of  an  inch  from  the  tooth,  according  to  the  depth  of  the 


NATURAL,   ROOT   AND   ARTIFICIAL   CROWN. 


651 


canal.  If  the  canals  in  crown 
and  root  are  equal  in  size,  the 
pivot  is  ready  to  be  pressed  into 
place,  which  should  be  done  M'ith 
the  thumb  and  forefinger,  if  the 
pivot  is  made  of  compressed 
wood.  But  if  the  canals  differ 
in  size,  the  wood  must  be  com- 
pressed to  the  size  of  the  larger, 
and  then  trimmed  down  to  fit  the 
smaller.  The  end  thus  trimmed 
should  require  more  force  for  its 
introduction,  since  the  compressed 
wood  swells  most  from  moisture. 
The  part  of  the  pivot  going  into 
the  root,  if  made  of  compressed 
wood,  should  never  be  so  large  as 
to  require  any  other  pressure  than 
that  which  can  be  applied  with 
the  thumb  and  forefinger,  as  the 
swelling  of  the  wood  will  soon 
render  it  sufficiently  tight  to  hold 
it  firmly  in  its  place ;  and  if  too 
tight,  the  subsequent  swelling  will 
split  the  r.oot.  The  practice  of 
driving  a  pivot  up  with  a  hammer, 
or  by  very  strong  pressure,  as  is 
often  done,  is  a  bad  one.  It  is 
apt  to  cause  inflammation  and 
suppuration  of  the  soft  tissues 
about  the  apex  of  the  root.  The 
utmost  force  admissible,  and  this 
only  in  the  case  of  uncompressed 
pivot  wood,  is  somewhat  more 
than  can  be  made  with  the  thumb  and  finger,  applied  by  means  of  a 
small  piece  of  wood,  notched  at  the  end,  to  receive  the  cutting  edge 
of  the  tooth. 

It  is  important  that  the  pivot  should  exactly  equal  the  depth  of  the 
canal.  If  too  long,  the  crown  will  not  go  up  to  its  place  ;  if  too  short, 
there  will  be  either  an  unnecessary  weakening  of  the  root,  or  the 
crown  will  be  insecure.  A  small  piece  of  smooth  wire  or  knitting 
needle,  with  a  sliding  collar  of  wood  or  gutta-percha,  forms  a  simple 
instrument  for  measuring  the  depth  of  the  canal  in  the  root.    Fig.  426 


652  MECHANICS. 

represents  a  convenient  gauge  for  this  purpose.  A  porcelain  tooth 
with  a  wooden  pivot  presents,  before  insertion,  the  appearance  repre- 
sented in  Fig.  425. 

Fig.  425.  Fig.  426. 


When  a  metallic  pivot  is  used,  the  end  going  into  the  artificial 
crown  may  be  fastened  in  either  of  the  following  ways.  First,  by 
cutting  a  screw  on  it,  either  with  a  file,  or  passing  it  through  a  screw- 
plate  ;  the  cavity  in  the  crown  should  next  be  filled  with  a  wooden 
tube,  and  the  pivot  then  screwed  into  it ;  or  the  pivot  may  be  first 
■  screwed  into  a  small  block  of  pivot  wood,  and  the  wood  then  trimmed 
to  fit  the  crown.  Second,  by  filling  the  pivot  hole  with  pulverized 
borax,  moistened  with  water,  inserting  the  end  of  the  pivot  into  it, 
which  should  be  large  enough  to  fill  the  cavity,  placing  several  small 
pieces  of  solder  around  it,  and  fusing  them  with  the  blowpipe.  The 
solder,  adapting  itself,  when  in  a  state  of  fusion,  to  the  rough  walls  of 
the  cavity  in  the  crown  of  the  tooth,  will  prevent  the  pivot  from 
loosening  or  coming  out ;  or  the  metallic  pivot  may  be  attached  to 
the  porcelain  crown  by  "  firing"  with  jeweller's  enamel ;  shellac  is  also 
used  for  fastening  the  pivot  in  both  crown  and  root,  for  the  latter  in 
the  form  of  powder,  the  pivot  being  warmed  to  soften  it.  The  pro- 
jecting part  of  the  pivot  should  be  about  half  an  inch  in  length.  By 
some  it  is  made  square  and  pointed,  as  in  the  figure ;  but  the  best  form 
is  a  polished  cylinder.  The  latter  resists  more  firmly  any  downward 
traction,  while  the  curve  of  the  face  of  the  root  will  pre- 
FiG.  427.  ygjj^  j^jjg  pivot  turning  on  its  axis.  The  cavity  in  the 
root,  which  requires  to  be  deeper  for  a  metallic  than  for 
a  wood  pivot,  may  be  filled  with  wood,  having  a  small 
hole  through  the  centre.  Into  this,  the  end  of  the  pivot 
is  introduced  and  forced  up,  until  the  tooth  and  root  come 
firmly  together.  The  appearance  of  a  porcelain  tooth  prepared  with 
a  metallic  pivot,  for  insertion  in  this  manner,  is  shown  in  Fig.  427. 

But  when  a  metallic  pivot  is  used,  a  plate  tooth  is  preferable  to  one 
made  expressly  for  pivoting.  The  manner  of  attaching  a  pivot  to  the 
former  is  as  follows :  The  root  is  first  prepared,  after  which  an  im- 
pression is  taken  ;  from  this  a  plaster  model  is  made,  and  from  the 
latter  metallic  dies.  This  done,  a  piece  of  gold  plate,  large  enough 
to  cover  the  root,  should  be  swaged  up  between  the  dies ;  a  plate  tooth 
of  the  proper  size,  shape  and  color,  is  then  fitted  to  the  root,  backed 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN.  653 

with  gold,  and  soldered  to  the  plate.     To   the   upper 

or  convex  surface  of  this  last,  and  immediately  beneath 

the  canal  in  the  root,  a  gold  pivot  is  attached.     The 

position  and  direction  of  this  pivot  is  thus   secured. 

Press  the  plate,  covered  with  a  very  thin  film  of  wax, 

against  the  root ;  at  the  point  opposite  the  canal,  thus 

marked  on  the  plate,  drill  a  hole ;  through  this  pass  a  gold  pivot 

into  the  canal ;  press  softened  sealing  wax  around  the  part  of  the 

the  pivot  (made  purposely  too  long)   below  the  plate,  and  remove 

the  fixture  from  the  mouth.     Invest  the  upper  part  of  the  pin  and 

plate  in  plaster  (keeping  it,  by  means  of  a  minute  collar  of  wax,  out 

of  the  hole  through  which  the  pin  passes),  remove  the  sealing  wax, 

cut  off  the  pin  even  with  the  plate  and  solder.     A  front  and  side  view 

of  a  tooth  thus  prepared  is  shown  in  Fig.  428. 

A  pivot,  consisting  of  gold  encased  in  a  thin  layer  of  wood,  consti- 
tutes a  secure  means  of  attachment.  It  is  prepared  in  the  following 
manner :  The  gold  is  first  made  into  wire  of  proper  size,  and  passed 
through  a  screw  plate ;  a  hole  is  then  drilled  lengthwise  into  a  piece 
of  well-seasoned  hickory,  as  far  as  required  for  the  length  of  the  pivot, 
and  a  thread  cut  with  the  corresponding  screw  tap ;  into  this  the  wire 
is  screwed,  and  then  cut  off  close  to  the  wood,  which  is  reduced  with  a 
file  or  knife  nearly  to  the  size  of  the  orifice  in  the  artificial  crown,  and 
then  condensed  by  passing  through  a  pivot  draw  plate.  Subsequent 
manipulations  are  the  same  as  given  for  the  simple  wooden  pivot ;  from 
which  it  differs  in  being  stronger,  also  in  permitting  a  slight  bend  in 
the  pivot  in  case  the  canals  in  root  and  crown  are  not  in  precisely  the 
same  direction.  The  wood  prevents  the  gold  from  enlarging  the  cavity 
of  the  root,  or  from  being  worn  by  friction  in  the  pivot  hole  of  the 
artificial  tooth ;  and  at  the  same  time,  by  the  swelling  of  this  encase- 
ment, the  pivot  is  firmly  retained  in  both. 

Another  method  is  to  screw  a  gold  cylinder  into  the  root,  and  fill 
around  it  with  gold  where  any  space  exists,  the  lower  part  of  the  canal 
being  enlarged  and  undercut  for  the  purpose.  A  disk  of  plate  gold  or 
platinum  is  then  accurately  fitted  to  the  exposed  surface  of  the  root, 
to  which  a  split  pivot  and  the  plain  plate  tooth  are  soldered. 

Another  method  is  to  fill  the  root  solid  with  gold,  and  to  build  the 
gold  over  the  exposed  surface.  A  hole  for  the  reception  of  the  pivot 
is  then  drilled  in  the  centre  of  the  gold  filling ;  amalgam  may  be  sub- 
stituted for  the  gold. 

In  1849  Henry  Lawrence  obtained  a  patent  for  a  pivot  tooth,  which 
consisted  of  an  ordinary  pivot  crown,  with  a  hole  entirely  through  it, 
ending  in  a  countersink,  to  accommodate  the  head  of  a  screw  of  gold 
or  other  suitable  metal,  by  which  the  crown  was  secured  to  the  root. 


654  MECHANICS. 

A  method  of  pivoting  suggested  by  Dr.  E.  "VV.  Foster  combines 
the  screw  of  Woofendale  with  the  wood  casing  in  the  root,  the  novel 
features  being  a  rounded  head  to  the  screw  and  a  rounded  cavity 
in  the  crown  for  its  reception.  Fig.  429  shows  the  crown  screw  and 
method. 

The  pulp  canal  is  enlarged  by  the  drill  sufficiently  to  accommodate 

a  compressed   hickory  pivot,  the   canal   above  it   being  filled  with 

gold.     The  wood  pivot  is  cut  off  flush  with 

the  exposed  surface  of  root,  and  the  crown 

fitted  and  held  in  position  while  a  drill  is 

passed  through  the  hole  in  the  crown,  and 

an  opening  made  through  the   wood  pivot 

in  the  root.     A  steel  screw  then  attaches 

the   crown    to   the    root,  between   which  a 

few  layers  of  gold  foil  are  placed.     Gold  is 

then  packed  in  the  hole  in  the  crown  over 

the  screw  head..    Gutta  percha  or  one  of  the  zinc  preparations  may  be 

used  between  the  crown  and  root,  instead  of  the  layers  of  gold  foil. 

As  a  general  rule,  not  more  than  two  roots  should  be  prepared  at 
one  sitting,  though  sometimes  four,  or  even  six,  may  be  prepared  with- 
out incurring  any  risk.  When  a  tooth  is  attached  by  any  of  the 
ordinary  modes  of  pivoting,  the  walls  of  the  canal  in  the  root  are,  of 
necessity,  exposed  to  the  action  of  the  fluids  of  the  mouth,  and,  conse- 
quently, are  gradually  softened  and  broken  down;  so  that,  in  the 
course  of  a  few  years,  a  larger  pivot  will  be  required,  and  this,  too, 
will  have  to  be  again  replaced  with  one  still  larger,  until,  finally,  the 
root  is  destroyed.  This  destructive  process  proceeds  more  rapidly  in 
some  cases  than  in  others,  accordingly  as  the  root  is  hard  or  soft,  and 
as  the  secretions  of  the  mouth  are  in  a  healthy  or  vitiated  condition. 
This  may  be  prevented  by  introducing  a  gold  cylinder  for  the  reception 
of  the  pivot.  This  protects  the  Avails  of  the  canal  against  the  action 
of  corrosive  agents,  and  a  root  thus  prepared  will  sujDport  an  artificial 
crown  more  than  twice  as  long  as  when  prepared  in  the  ordinary  way. 
The  operation,  however,  is  more  tedious  and  expensive,  and  only  the 
larger  roots  will  permit  the  enlarged  size  of  canal  required. 

For  the  preparation  of  a  tooth  in  this  manner,  the  following  is  the 
method  of  procedure  :  First,  the  crown  of  the  natural  tooth  is  removed, 
the  pulp,  if  alive,  destroyed,  and  the  canal  in  the  root  enlarged  as 
before  directed.  Secondly,  a  screw-tap  is  introduced  for  the  purpose 
of  cutting  a  screw  on  its  inner  walls.  Thirdly,  a  corresponding  screw- 
thread  is  cut  on  a  piece  of  hollow  gold  wire,  during  which  process  the 
gold  tube  is  slipped  over  a  steel  mandrel,  to  prevent  compression.  This 
done,  it  may  be  screwed  into  the  root  about  a  quarter  of  an  inch  ;  the 


NATURAL   HOOT   AND   ARTIFICIAL   CROWN.  655 

mandrel  is  then  withdrawn,  and  the  lower  or  protruding  extremity 
dressed  off,  even  with  the  root,  with  a  very  fine  file.  Fourthly,  an 
artificial  tooth  is  selected,  of  the  right  size,  shape,  and  color,  and  fitted 
to  the  root ;  after  which  a  gold  pivot  is  fixed  in  it  in  the  manner  before 
described,  corresponding  in  size  and  length  to  the  gold  tube  in  the  root. 
Having  proceeded  thus  far,  the  operation  is  completed  by  applying 
the  tooth  to  the  root,  but  little  pressure  being  required  to  force  up  the 
pivot. 

The  stability  of  a  tooth  secured  in  this  manner,  if  the  pivot  be  of 
the  proper  size,  is  as  great  when  first  inserted  as  one  prepared  by  any 
of  the  other  methods,  and  it  may  be  removed,  cleansed,  and  replaced 
at  the  pleasure  of  the  patient.  But  metal  against  metal  inevitably 
wears,  and  rapidly  so,  if  removed  from  time  to  time.  Hence  many 
prefer  the  wooden  pivot,  with  a  wire  run  through  its  centre.  When 
the  walls  of  the  canal  are  so  much  enlarged  by  decay  as  to  have  formed 
a  conical-shaped  cavity  in  the  lower  extremity  of  the  root,  the  upper 
end  only  of  the  cylindrical  screw  will  take  effect.  Jn  this  case,  the 
space  between  the  lower  extremity  and  the  walls  of  the  root  must  be 
thoroughly  filled  with  gold  before  the  wire  on  the  inside  is  with- 
drawn ;  after  which  the  tube  and  extruding  portions  of  the  gold  are 
filed  off  even  with  the  root,  and  polished,  before  the  artificial  tooth  is 
applied. 

.The  hollow  wire  is  made  by  partly  folding  a  narrow,  evenly-cut  strip 
of  gold  around  a  steel  mandrel  (a  knitting-needle  makes  an  excellent 
one),  and  passing  through  a  draw  plate ;  withdraw  the  mandrel  and 
solder  the  seam ;  then  replace  the  mandrel,  and  complete  the  drawing 
until  the  proper  thickness  is  given.  If  too  thin,  it  will  not  hold  the 
screw  thread  ;  if  too  thick,  it  will  either  make  the  canal  too  small  or 
require  too  large  an  opening  in  the  root.  Hollow  wire  may  be  pro- 
cured of  the  proper  size  at  less  expense  of  time  and  money  than  it  can 
be  made  by  a  dentist.  It  is  known  by  jewelers  as  joint  wire,  because 
used  for  the  hinges  of  breast-pins,  etc. ;  but  such  wire  is  rarely  over 
twelve  carats  fine. 

It  sometimes  happens  that  the  natural  root,  instead  of  occupying  its 
proper  position  in  the  jaw,  runs  very  obliquely ;  so  that  if  the  pivot 
connecting  the  artificial  tooth  to  it  be  straight,  the  latter  will  either 
overlap  the  adjoining  teeth  or  else  project  outward  or  inward.  To 
obviate  this,  an  angle  should  be  given  to  the  pivot,  immediately  at 
the  point  of  junction  between  the  tooth  and  root.  If  this  obliquity 
be  slight,  the  wooden  pivot,  stiffened  with  wire,  can  easily  be  bent 
to  suit;  but  in  cases  of  greater  obliquity,  a  solid  gold  pin  will  be 
required. 

Some  cases  are  met  with  presenting  a  more  formidable  difiiculty ; 


656  MECHANICS. 

as,  for  example,  when  the  root  is  situated  behind  the  circle  of  the  other 
teeth.  In  a  case  of  this  sort,  a  different  kind  of  tooth  and  an  entirely 
different  course  of  procedure  is  necessary.  After  having  prepared  the 
root,  an  impression  of  the  parts  is  taken  in  wax,  from  which  a  plaster 
model  is  obtained,  and  from  this  two  metallic  dies.  With  these  a 
gold  plate  is  to  be  swaged,  extending  backward  so  as  to  cover  the  root, 
and  forward  to  form  a  line  with  the  outer  circle  of  the  teeth.  To  the 
posterior  part  of  the  plate  covering  the  root,  and  directly  beneath  the 
cavity  in  it,  a  gold  pivot,  about  three-eighths  of  an  inch  long,  is  sol- 
dered, and  to  the  anterior  part  of  it  a  plate  tooth  of  the  right  size, 
shape  and  shade  is  attached.  A  piece  of  hollow 
Fig.  430.  Fig.  431.  wood,  or  a  hollow  gold  screw  as  before  described,  is 
now  introduced  into  the  root,  and  into  this  the  gold 
pivot  is  inserted.  A  right  superior  central  incisor, 
mounted  on  a  plate  with  a  pivot,  for  insertion  in 
the  manner  here  described,  is  represented  in  Figs. 
430  and  431. 
A  method  of  inserting  an  artificial  tooth  on  a  metallic  pivot  is  de- 
scribed by  the  late  Dr.  James  B.  Beau,  in  Vol.  Ill,  1869-70,  of  the 
American  Journal  of  Dental  Science.  "  Having  filed  or  sawed  off 
the  remaining  portions  of  the  crown,  the  exposed  surface  of  the  root 
is  smoothly  filed  to  within  one-half  or  one-fourth  of  a  line  below  the 
margin  of  the  gum,  giving  it  a  slight  concave  appearance,  so  as  to 
accommodate  the  neck  of  the  plate  tooth  which  is  to  rest  against  it. 
It  is  well  at  this  stage  of  the  operation  to  stop  the  canal  loosely  with 
a  pellet  of  cotton  or  floss  silk  saturated  with  spirits  of  camphor,  and 
to  dismiss  the  patient  for  two  or  three  days.  If  no  inflammation  be 
present,  the  canal  may  then  be  cleaned  out  and  carefully  filled  with 
gold  foil  from  the  apex  to  within  four  or  five  lines  of  the  orifice. 

"  The  remaining  portion  of  the  canal  not  filled  should  now  be  enlarged 
to  about  one  line  in  diameter,  if  the  size  of  the  root  will  admit  of  it, 
down  to  the  gold  filling,  making  the  bottom  smooth  and  solid  and  the 
sides  parallel.  The  orifice,  to  the  depth  of  nearly  a  line,  is  again 
enlarged  with  a  burr-drill  to  about  two  lines  in  diameter,  and  a  small 
groove  or  undercut  is  formed  around  the  margin  for  the  retention  of 
the  gold  filling  subsequently  to  be  introduced  around  the  tube. 

"  Hollow  gold,  jeweler's  wire,  or  simple  gold  tubes  made  of  gold 
plate,  may  be  employed.  If  the  latter  is  chosen,  it  is  formed  by 
bending  a  piece  of  ordinary  gold  plate  around  a  wire,  so  as  to  form  a 
cylinder  sufliciently  large  to  fit  the  smaller  portion  of  the  canal  pre- 
pared for  it ;  then  solder  with  the  finest  gold  solder.  A  piece  of  the 
tube  half  an  inch  in  length  should  be  cemented  with  shellac  into  a  hole 
bored  through  a  piece  of  wood  half  an  inch  in  thickness,  to  serve  for 


NATUEAL   ROOT   AND   ARTIFICIAL   CROWN.  657 

a  handle ;  the  interior  is  then  carefully  dressed  out  with  a  jeweler's 
broach  which  has  a  slight  taper,  making  it  smooth  and  regular  within. 
A  solid  gold  wire  pivot  is  now  carefully  filed  and  fitted,  by  grinding 
it  with  fine  emery  and  water,  making  a '  ground  joint,'  whereby  the 
pivot  is  firmly  held  when  in  place.  Any  portion  of  the  wire  that 
may  j^roject  beyond  the  smaller  end  of  the  tube  should  be  cut  evenly 
off,  while  at  the  larger  end  it  should  project  at  least  one-fourth  of  an 
inch. 

"  The  tube  must  be  taken  out  of  the  cement  and  a  piece  of  plate 
soldered  to  the  smaller  end,  forming  a  bottom.  An  easier  flowing 
solder  should  be  used  for  this,  so  as  not  to  disturb  the  first.  This  tube 
thus  formed,  after  being  cleansed  in  acid  and  smoothly  filed,  is  ready 
to  be  inserted  into  the  root. 

"  Some  have  proposed  to  cut  a  screw  on  the  tube,  whereby  it  is  firmly 
secured  in  its  place,  and  to  fill  then  around  with  gold.  But  the  most 
convenient  way  is  to  cut  a  number  of  barbs  with  a  sharp  knife  on  the 
outside  looking  toward  the  open  end  ;  this  retains  the  gold  in  place 
nearly  or  quite  as  well  as  the  screw.  Being  made  so  as  to  enter  the 
root  rather  loosely,  several  folds  of  gold  foil  are  wrapped  around  it, 
and  after  carefully  drying  the  parts  with  bibulous  paper — the  pivot 
being  in  its  place  in  the  tube — the  whole  is  forced  to  the  bottom  of  the 
cavity,  and  the  loose  portions  of  foil  removed. 

"  Having  previously  prepared  some  cohesive  foil,  the  space  around 
the  tube  is  perfectly  filled  with  gold.  The  gold  pivot  is  now  removed, 
and  the  tube  carefully  sawed  or  filed  off"  nearly  level  with  the  end  of 
the  root,  and  the  surface  of  the  gold  and  the  root  well  polished. 

"  Thus  far  we  have  the  root  preserved  with  a  good  filling,  and  a  gold 
tube  firmly  secured  in  it  containing  an  accurately  fitting  gold  pivot. 

"  The  next  operation  is  to  attach  a  suitable  tooth  to  the  pivot,  and 
for  this  purpose  a  plain  plate  tooth  is  selected  that  will  be  suitable  in 
size,  shape  and  color.  This  tooth  should  be  so  ground  and  fitted  to  the 
anterior  edge  of  the  root  that  the  free  margin  of  the  gums  will  cover 
the  point  of  union.  Then  after  soldei-ing  a  strong  backing  to  the  :ooth, 
it  is  fitted  to  its  position,  with  the  gold  pivot  in  place,  on  which  has 
been  soldered  a  small  shoulder  or  ring  of  plate,  and  the  projecting 
portion  of  the  wire  cut  off".  This  shoulder  is  to  be  made  in  the  form  of 
a  disk,  cut  out  of  gold  plate,  larger  than  the  diameter  of  the  pivot,  then 
perforated  with  a  hole  just  large  enough  to  admit  the  pivot  up  to  the 
point,  a  little  less  than  the  depth  of  the  tube.  Being  retained  at  this 
point,  it  is  made  to  fit  closely  down  on  the  root ;  the  whole  is  then  care- 
fully withdrawn  and  bedded  up  to  the  ring  in  plaster  and  asbestos, 
thoroughly  dried,  the  wax  removed,  and  the  piece  soldered  with  fine 
solder.  If  the  ring  is  loose,  it  must  be  kept  in  place  by  wax  or  plaster 
42 


658  MECHANICS. 

in  the  act  of  withdrawing  it  from  the  tube.  The  pivot  is  again  tried 
in  the  mouth,  and  if  satisfactory,  the  projecting  portion  is  cut  off, 
smoothly  filed,  and  the  tooth  attached  to  it  with  shellac  ;  then  try  in 
the  mouth,  and  alter  its  position  if  necessary.  If  the  pivot  does  not  fit 
too  tightly,  the  whole  can  be  withdrawn  together,  carefully  invested  in 
plaster  and  asbestos,  and  strongly  soldered.  The  piece  is  now  finished 
up,  reducing  the  shoulder  around  the  pivot  to  less  than  half  a  line  in 
breadth  ;  a  large  plate  covering  the  end  of  the  root  has  no  advantage, 
and  would  only  form  a  lodgment  for  food  and  the  secretions  of  the 
mouth,  inducing  decomposition  and  the  destruction  of  the  root. 

"  If  the  pivot  is  not  retained  sufiiciently  firm  in  the  tube,  it  may  be 
wrapped  with  a  few  fibres  of  floss  silk  or  cotton,  and  when  forced  into 
its  place  with  a  slight  rotary  motion,  it  will  remain  quite  firm,  and  can 
be  used  with  great  satisfaction.  If  the  adjustments  have  been  properly 
made,  the  shoulder  or  flange  will  fit  closely  on  the  edge  of  the  tube, 
the  neck  of  the  tooth  resting  on  the  beveled  edge  made  for  it,  thereby 
preventiDg  the  tooth  from  turning  on  its  axis.  Proper  care  and  clean- 
liness, removing  the  tooth  at  least  three  times  a  week,  will  enable  such 
a  piece  to  be  used  with  satisfaction  for  many  years." 
Fig.  432.  -pj^^  ^^9  represents  an  antero-posterior  section  of  a 

^mk.  superior  central  incisor  root  pivoted  in  the  manner 

/HKI  above  described,  a,  dentine  of  root;  6,  porcelain  tooth  ; 

tm-A  ^'  pivot  surrounded  by  the  tube ;  d,  backing,  which  is 

i^-HM  soldered  to  the  tooth  and  to  the  pivot ;  e,  filling  be- 

i    j^^^M  tweeu  the  end  of  tube  and  apex  of  the  root ;  /,  filling 

\  ^^^Kf    ■■■"       around  the  tube  by  which  it  is  retained  in  place  ;  g, 
"'••i^^pK-''  flange  resting  on  the  edge  of  the  tube;  li,  junction  of 

1  r^  the  tooth  and  root,  concealed  by  the  margin  of  gum. 

||pg  Another  method  for  inserting  an  artificial  crown  on 

^  a  metallic  pivot  is  that  of  Dr.  T.  J.  Thomas,  by  which 

the  end  of  the  root  is  protected  from  the  action  of  deleterious  agents, 
and  a  firm  support  given  to  the  tooth.  It  is  thus  described  by  Prof 
Gorgas : — 

"  Prepare  the  root  as  for  an  ordinary  wooden  pivot ;  then  select  a 
'plaie  tooth  of  the  proper  size,  shape  and  shade,  and  fit  it  by  grinding 
accurately  to  the  prepared  root. 

"After  this  is  done,  enlarge  the  pulp  canal  by  reaming  it  out  as 
large  as  the  root  will  permit ;  that  is,  make  a  conical-shaped  cavity 
in  the  exposed  surface  of  the  root,  allowing  the  margin  of  this  cavity 
to  be  quite  near  to  the  periphery  of  the  root,  with  slight  undercuts  or 
retaining  points  on  the  anterior  and  posterior  walls. 

"After  this  cavity  is  prepared,  and  that  portion  of  the  pulp  canal 
beyond  it  filled  to  the  apex  of  the  root  with  gold,  make  a  square  me- 


NATURAL    ROOT   AND   ARTIFICIAL   CROWN.  659 

tallic  pivot  of  twenty-carat  gold  alloyed  with  platinum,  in  the  propor- 
tion of  five  parts  of  gold  to  one  of  platinum.  This  pivot  is  made  in 
two  parts,  which  are  soldered  together  at  the  base  of  the  artificial 
crown,  and  slightly  wedge-shaped.  After  the  pivot  is  prepared,  a  thin 
piece  of  platinum  plate  is  bent  around  it,  thus  forming  a  square  cylin- 
der into  which  the  pivot  perfectly  fits.  The  pivot  is  then  carefully 
drawn  out  of  the  square  cylinder,  and  the  edges  of  this  cylinder  sol- 
dered with  pure  gold.  The  pivot  is  again  inserted,  and  the  excess 
of  solder  and  any  rough  edges  which  may  be  found  in  the  cylinder 
filed  ofl^ 

"  After  this  is  done,  the  cavity  in  the  root  is  carefully  dried  and 
protected  from  moisture,  and  the  square  cylinder,  with  the  pivot  inside 
of  it,  is  placed  in  the  centre  of  this  cavity,  which  is  filled  around  it 
with  gold  in  as  careful  and  perfect  a  manner  as  any  crown  cavity. 
The  gold  is  allowed  to  overlap  the  margin  of  the  cavity,  so  as  to  per- 
fectly protect  all  of  the  exposed — or  what,  in  the  ordinary  method, 
would  be  the  exposed — surface  of  the  root. 

"  The  gold  filling,  besides  protecting  the  root,  retains  the  square 
cylinder  in  the  centre  of  it.  In  placing  the  cylinder  in  the  root  with 
the  pivot  in  it,  preparatory  to  inserting  the  gold  filling  around  it,  the 
split  in  the  pivot  should  range  directly  back  from  the  labial  to  the 
palatine  surfaces,  and  not  transversely.  The  pivot,  after  the  filling  is 
inserted,  is  drawn  out  of  the  cylinder,  which  remains  firmly  fixed  in 
the  root,  and  that  part  of  the  cylinder  which  projects  beyond  the  gold 
is  filed  down  to  a  level  with  the  surface  of  the  filling.  An  impression 
of  this  surface  is  then  taken  with  wax  or  gutta  percha,  and  die  and 
counter-die  made  of  fusible  metal,  by  means  of  which  a  disk  of  plati- 
num plate  is  swaged  to  fit  accurately  the  concave  surface  of  the  gold 
filling  in  the  root. 

"  When  this  is  done,  the  convex  surface  of  the  disk  is  thinly  covered 
with  wax,  and  the  disk  placed  in  its  proper  position  over  the  gold  filling 
in  the  root,  and  slightly  pressed  on  it,  in  order  to  obtain  an  impression 
of  the  square  orifice  of  the  cylinder,  by  which  a  hole  corresponding  in 
shape  and  position  may  be  cut  in  the  disk.  The  outer  end  of  the  pivot 
is  then  inserted  in  the  square  hole  made  in  the  disk,  secured  by  means 
of  wax,  and  the  whole  returned  to  the  root  (with  pivot  in  the  cylinder), 
in  order  to  make  certain  that  the  pivot  is  in  its  proper  position ;  then 
it  is  carefully  removed  and  secured  by  an  investment  of  plaster  and 
asbestos,  that  the  pivot  may  be  soldered  to  the  disk. 

"The  projecting  portion  of  the  pivot  above  is  filed  down  to  a  level 
with  the  concave  surface  of  the  disk,  and  the  disk  and  pivot  returned 
to  the  cylinder  in  the  root,  when  the  plate  tooth  is  placed  in  position 
and  secured  to  the  disk  by  means  of  wax. 


660 


MECHANICS. 


"This  done,  the  pivot,  disk  and  the  plate  tooth  are  carefully  re- 
moved, and  invested  in  plaster  and  asbestos,  in  order  that  a  backing 
of  gold  may  be  made,  and  the  toqth  soldered  to  it  and  the  disk.  The 
tooth  is  now  ready  to  be  inserted,  and  by  slightly  separating  the  two 
parts  which  form  the  pivot,  at  its  apex  or  free  extremity,  it  will  tightly 
fit  the  cylinder,  the  two  halves  acting  as  springs,  and  pressing  against 
the  walls  of  the  square  cylinder  inserted  in  the  root." 

The  late  Dr.  M.  H.  Webb  suggested  several  methods  of  pivoting  by 
which  gold  crowns  with  porcelain  faces  made  of  plain  plate  teeth  are 
attached  to  natural  roots. 

One  of  these  methods  consists  in  soldering  to  a  plain  plate  tooth 
with  straight  pins,  a  narrow  strip  of  heavy  gold  plate  beveled  on  its 
sides  toward  the  tooth,  and  long  enough  to  form  the  pivot  extending 
into  the  root. 

When  ready  for  insertion,  gold  is  packed  around  the  pivot  (being 
anchored  in  the  root  by  means  of  undercuts),  and  behind  the  beveled 

Fig.  433. 


edges  of  the  backing,  and  so  built  up  as  to  form  a  contour  palatine 
surface  on  the  crown.     (Fig.  433.) 

Another  method  of  Dr.  Webb's  is  to  back  with  gold  plate  a  plain 
plate  tooth  with  straight  pins,  the  sides  of  the  backing  being  bent  to 
form  a  tube  or  canula.  Through  this  tube  a  gold  pivot  passes  into  the 
root,  and  cohesive  gold  is  employed  to  secure  the  pivot  to  both  crown 
and  root,  by  packing  it  around  the  pivot  in  the  root,  around  the  tube 
on  the  backing,  and  into  the  dovetailed  grooves  in  the  crown  (Fig. 
4.34).  This  plan  is  a  modification  of  that  suggested  by  Dr.  W.  H. 
Dwindle,  to  be  used  in  connection  with  crystal  gold. 

A  method  of  no  recent  date  is,  to  take  an  impression  of  the  root  sur- 
face and  adjoining  teeth;  and  to  drill  a  hole  in  the  plaster  model  thus 
obtained,  to  correspo'nd  to  the  canal  or  canals  of  bicuspids  and  molars. 
Into  these  holes  gold,  platinum,  or  platinum-and-iridium  alloy  pins  are 
inserted,  and  to  these  a  disk  covering  the  exposed  surface  of  the  root 
is  soldered.     A  plate  tooth  is  then  adapted  by  grinding  and  soldered 


NATURAL    ROOT   AND    ARTIFICIAL    CROWN. 


661 


to  the  disk,  the  plaster  model  serving  as  a  guide  for  the  adaptation  of 
both  pins  and  crown.  Fig.  435  represents  the  tooth  prepared  for 
insertion  into  the  root  by  means  of  gutta  percha  or  zinc  preparation, 
the  pins  being  roughened  or  barbed,  being  made  square  for  the  latter 
purpose.  When  the  roots  are  filled  with  gutta-percha,  the  pins  and 
crown  are  warmed  and  pressed  into  place. 

Dr.  J.  F.  Flagg  suggests  the  following  method  of  pivoting,  shown  in 
Fig.  436,  and  described  by  him  as  follows : — "  Select  plate  tooth,  fit 
it  to  root,  and  bevel  it  from  near  the  pin — cervical — or  pins,  if  cross- 
pins,  to  the  labio-cervical  edge.  Solder  a  platinum  pin  to  it  as  a 
backstay  and  pivot  combined,  leaving  it  rough  or  grooved  on  both 
sides  of  the  pin  for  a  retaining  hold  to  the  finishing  palatal  amalgam. 

"  Fill  the  root  *  *  *  i  prefer  to  give  this  ('cement')  a  day  to 
harden  thoroughly.  In  the  root  filling  drill  a  hole  larger  than  the 
platinum  pin,  as  near  to  the  palatal  portion  of  the  filling  as  possible, 
and  directed  slantwise  to  the  apical  centre  of  root-filling ;  then  fissure- 


FiG.  434. 


Fig.  435. 


Fig.  436. 


drill  the  hole  toward  the  labial  side  of  the  now  oval  pivot  hole.  By 
this  method  the  tooth  is  accurately  placed  in  position,  and  easily  held 
firmly  in  place  while  the  pin  is  secured  by  filling  the  pivot  hole  with 
amalgam.  Let  this  harden  for  half  an  hour,  and  then  add  amalgam 
in  contour  to  the  root  filling  and  palatal  face  of  the  porcelain  tooth. 
It  is  at  this  point  of  the  operation  that  the  need  for  '  beveling '  the 
cervical  portion  of  the  tooth  is  demonstrated,  for,  by  this  bevel,  one 
is  enabled  to  make,  by  filling,  a  perfectly  tight  joint  at  the  labio- 
cervical  junction  of  tooth  with  root,  and  also  to  secure  a  strength 
of  amalgam  equal  to  the  entire  surfaceof  root-filling." 

Dr.  Boice  modifies  Dr.  Flagg's  method  by  cutting  a  groove  across 
the  tooth  between  the  pins  before  attaching  the  platinum  pivot,  for  the 
purpose  of  leaving  a  space  behind  the  pivot  for  the  better  support  of 
the  amalgam  with  which  it  is  filled. 

Dr.  H.  Weston's  method  consists  of  a  special  crown  with  a  depres- 
sion on  its  palatal  surface,  within  which  are  the  tooth-pins  and  a  spear- 
shaped  pivot  of  hard  platinum,  or  platinum-and-iridium  alloy,  notched 


662 


MECHANICS. 


Fig.  437 


on  both  edges,  to  the  crown  end  of  which  a  backing  of  the  same  metal 
is  soldered,  giving  the  pivot  with  the  backing  (which  is  to  be  soldered 
to  it)  a  T-shape  (Fig.  437).  The  root  canal  being  enlarged  and 
undercut  with  a  wheel-drill,  and  the  crown  fitted  to  the  root  and  pivot, 
the  latter  is  secured  in  the  root  by  packing  around 
it  either  amalgam,  gold,  or  zinc  preparation. 

Dr.  E.  L.  Hunter's  method  consists  in  making  a 
pivot  of  gold  alloyed  with  platinum,  with  a  thread 
cut  on  one  end,  by  means  of  which  it  is  screwed 
into  the  root  canal,  the  other  end  of  the  pivot 
being  split.  Several  screws  are  inserted  into  the 
root  around  the  pulp  canal,  to  afford  anchorage  to 
the  gold  which  is  packed  about  them  and  the 
pivot  projecting  from  the  canal.  A  pivot  crown 
being  adapted  to  the  root  surface,  the  split  end  of 
the  pivot  is  sprung  open  and  the  crown  forced  to 
its  place,  being  firmly  held  by  the  split  end  of  the 
pivot. 

Dr.  G.  P.  Carman  modifies  Dr.  Hunter's  method 
by  using  an  ordinary  pivot  crown,  with  the  hole  drilled  completely 
through  it  (Fig.  438).  The  split  or  cleft  end  of  the  pivot  is  made  to 
fit  loosely  in  the  hole  in  the  crown,  so  that  gold  maybe  packed  around 
it,  to  hold  the  crown  firmly. 

A  method  of  pivoting  devised  by  Dr.  H.  K.  Leecu  (Fig.  439)  is 
described  also  by  Dr.  Dexter,  as  follows:  The  root  is  drilled  out,  to 
a  depth  of  about  three-eighths  of  an  inch,  to  a  diameter  of  No.  16 
standard  American  wire  gauge,  the  bottom  of  the  hole  being  flared  or 


Fig.  439. 


Fig.  438. 


enlarged,  and  the  canal  above  filled  with  gutta-percha.  A  gold  tube 
is  made  to  fit  the  hole  accurately  and  project  sufficiently  for  con- 
venience of  handling,  and  is  soldered  through  a  hole  in  a  gold  base 
struck  to  the  root,  projecting  through  the  plate  some  distance.     A 


NATURAL   ROOT   AND    ARTIFICIAL   CROWN. 


663 


plate-tooth  is  fitted  to  the  root  and  plate  and  soldered  to  the  latter, 
gold  being  flowed  on  to  the  plate  and  backing,  and  around  the  pro- 
jecting tube,  to  form  the  palatal  contour,  and  the  tube  cut  off  flush 
with  the  latter.  We  now  have  a  plate  tooth,  gold  backed,  with  a  tube 
pivot,  the  orifice  of  which  opens  on  the  palatal  aspect  of  our  tooth. 
The  root  end  of  the  tube  is  now  slit  perpendicularly  in  three  or  four 
places,  for  about  two-thirds  of  its  length,  a  thin  sheet  of  warmed  gutta- 
percha is  placed  on  the  base  of  the  crown  around  the  tube,  and  the 
whole  is  pushed  securely  to  place.  Now  pack  gold  or  tin  into  the 
tube,  condensing  the  bottom  portions  so  that  the  slit  end  will  spread  and 
tightly  Jill  the  flared  end  of  the  hole  in  the  root,  and  the  operation  is 
complete.  Dr.  Dexter  suggests  that  tin  be  used  to  fill  the  tube,  so 
that  the  tooth  may  be  easily  removed  in  case  of  trouble. 

Dr.  W.  G.  A.  Bonwill,  the  inventor  of  the  well  known  "  Bonwill 
Crowns,"  has  suggested  several  methods  of  pivoting,  but  the  latest,  con- 
sisting of  an  all-porcelain  crown,  he  considers,,  to  be  the  best.     These 

Fig.  440. 


teeth  are  made  in  special  moulds,  and  the  incisor  crowns  are  so  shaped 
as  to  form  a  dovetail,  which  allows  the  strain  outward  to  come  high 
up  near  the  cutting  edge,  and  not  to  depend  upon  the  palatal  wall  for 
support.  The  bicuspid  and  molar  crowns  are  cut  out  at  the  base, 
leaving  little  more  than  a  shell  with  undercuts  for  the  amalgam,  to  act 
as  dovetails,  the  operation  being  an  amalgam  filling  capped  with 
porcelain.  The  hollow  crowns  enable  the 
operator  to  fit  them  to  the  natural  roots  very 
readily,  as  there  is  little  material  to  grind  off. 

Fig.  440  represents  the  Bonwill  crowns  for  IH  DA/ 

the  incisors,  bicuspids  and  molars. 

Fig.  441  represents  the  latest  style  of  pins 
for  setting  the  Bonwill  crowns,  being  made 
of  special  metal,  and  of  a  shape  that  allows  of 
setting  in  four  different  directions.     After 


Fig.  441. 


664 


MECHANICS. 


the  crown  is  fitted  to  the  root,  the  pulp  canal  is  filled  with  amalgam  in 
a  plastic  condition,  and  the  triangular  barbed  metal  pin  is  forced  into 
it.  The  crown  is  then  filled  with  the  same  substance,  placed  over  the 
pin,  and  forced  to  its  place,  the  pin  resting  in  the  hole  in  the  crown. 
Several  modifications  of  this  method  are  suggested  by  the  inventor, 
such  as  a  nut  on  the  end  of  the  pin,  and  a  gas  vent  formed  by 
allowing  a  flat  side  of  the  pin  to  rest  against  one  wall  of  the  canal, 
and  the  space  kept  free  of  the  amalgam  when  it  is  packed  about  the 
pin.  Retaining  points  are  made  in  the  root  with  a  wheel  burr,  and  the 
amalgam  is  packed  in  the  countersunk  base  of  the  crown,  and  the 
surplus  escapes  by  the  opening  on  the  palatal  surface  in  the  case  of  an 
incisor  crown.  When  the  crown  is  well  pressed  into  its  place  on  the 
root,  the  amalgam  can  be  packed  in  around  the  pin.     The  too  free 

Fig.  442. 


escape  of  the  amalgam  through  the  palatal  opening  in  the  crown  can 
be  prevented  by  placing  the  thumb  or  index  finger  on  the  orifice  when 
pressing  up  the  crown.  The  tooth  should  be  kept  at  rest  until  the 
amalgam  has  hardened.  Fig.  442  represents  the  Gates-Bonwill  crowns, 
which  are  inserted  on  the  triangular  pins  in  the  same  manner  as  the 
crowns  just  described. 

Dr.  Bonwill  claims  that,  by  means  of  "  adjusters,"  Fig.  443,  the 
crowns  can  be  better  kept  in  position  immediately  after  the  operation 
than  with  the  fingers  or  forceps. 

Dr.  S.  Davis'  method  (Fig.  444)  is  to  prepare  the  root  as  usual,  and 
ream  out  the  chamber  in  a  funnel  shape,  and  cut  anchorages  in  the 
sides  of  the  reamed  surface.     A  plate-tooth  is  then  fitted,  by  grinding 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN. 


665 


it,  to  the  labio-cervical  edge  of  the  root,  and  backed  with  gold  plate, 
when  the  sides  of  the  tooth  and  backing  are  ground  to  bevel  sharply 
inward,  leaving  the  labial  surface  untouched.  A  gold  pivot  is  then 
soldered  to  the  backing,  of  such  a  length  that,  when  it  is  placed  in 
position,  a  narrow  space  is  left  between  the  crown  and  root.  The 
pivot  and  backing  are  then  roughened,  the  latter  being  barbed  and 


Fig.  445.    Fig.  446. 


Fig.  447. 


Fig.  448. 


Fig.  449.         Fig.  450 


Fig.  451.     Fig.  452. 


fastened  into  the  root  with  oxychloride  or  ox} 
phosphate  of  zinc.  Gold  is  then  packed  in  tl: 
retaining  points,  the  pulp  chamber  and  aroun  I 
the  pivot,  and  built  upon  the  backing  to  gi\ 
a  proper  form  to  the  inner  surface  of  the  crow 
of  the  tooth. 

The  four-pin  crowns,  invented   by  Dr.  ^ 
Storer  How,  are  among  the  more  recent  method 
of  pivot  work ;  and  the  following  description  oi 
the  successive  steps  to  be  taken  in  mounting 


666  MECHANICS. 

these   crowns  with   the   necessary  appliances  was   prepared    for  the 
present  edition  of  this  work  by  Dr.  How. 

1.  When  the  root  is  in  proper  condition  for  mounting,  measure  the 
depth  of  the  canal  by  means  of  the  canal  plugger  (Fig.  446)  and  its 
flexible  gauge  (Fig.  445),  and  fill  the  canal  at  and  a  short  distance 
from  the  apex  of  the  root,  keeping  the  gauge  at  position  to  show  the 
length  of  the  canal,  and  also  the  distance  to  which  it  has  been  filled. 

2.  Cut  ofi*  the  root  crown  with  the  excising  forceps,  and  a  round 
file,  down  to  the  gum  margin,  and,  with  the  barrel  burr,  No. 
241,  cut  the  labial  part  of  the  root  fairly  under  the  gum  without 
wounding  it. 

3.  Set  gauge  (Fig.  445)  on  a  Gates  drill  (Fig.  450),  to  one-half  the 
gauged  depth  of  the  canal,  and  drill  to  that  depth. 

4.  Set  the  twist  drill  (Fig.  449)  in  its  chuck  (Fig.  4536),  to  project 
the  same  length  as  the  Gates  drill,  and,  turning  the  chuck  with  thumb 
and  finger,  drill  the  root  to  exactly  that  depth. 

5.  Enlarge  the  mouth  of  the  canal  one-sixteenth  of  an  inch  deep  all 
around  to  near  the  margin  of  the  root,  using  the  square-end  fissure 
burr,  No.  59,  and  then,  with  the  oval.  No.  94,  under-cut  a  groove  at 
the  sides,  and  lingually,  as  shown  in  Fig.  451. 

6.  If  the  rubber  dam  is  to  be  used  for  a  gold  or  plastic  backing,  put 
it  now  over  the  root  with  Hunter's  root  clamp,  also  over  the  adjacent 
teeth,  and  thoroughly  dry  the  canal. 

7.  Set  the  tap  (Fig.  452)  in  its  chuck  (Fig.  453cy,  a  trifle  less  in 
length  than  the  drill ;  oil  the  tap,  and  carefully  tap  to  the  gauge 
depth. 

8.  Insert  the  post  in  its  chuck  (Fig.  453a)  to  the  exact  gauge  of  the 
tap,  and  turn  the  thumbscrew  down  hard  on  the  end  of  the  post ;  then 
screw  the  post  into  the  root;  release  the  thumbscrew;  unscrew  the 
chuck  a  half  turn;  bend  the  post  until  the  chuck  stands  in  centre  line 
with  the  adjoining  teeth,  and  unscrew  the  chuck. 

9.  Slit  the  rubber  back,  from  adjacent  teeth,  tucking  the  flaps  out 
of  the  way,  so  that  occlusion  may  be  tried,  and  the  post  excised  and 
ground  off",  until  the  teeth  close  clear  of  the  post. 

10.  Try  the  crown  on  the  post,  and,  with  an  F  disk,  dry,  grind  the 
rib  between  the  neck  pins  until  the  crown  is  labially  flush  with  the 
root  margin,  cutting  a  little  at  a  time  until  exactly  flush. 

11.  Take  the  crown  and  place  the  mandrel  (Fig.  454)  between  the 
pins  just  as  the  post  is  to  be,  and,  with  the  pliers  (Fig.  455),  bend  the 
pins  carefully  over  the  mandrel,  cutting  off"  the  pins  if  too  long  to  be 
pinched  in  on  the  mandrel  at  the  sides,  observing  that  the  pin  nearest 
the  cutting-edge  is  first  to  be  bent  (Fig.  4o7),  and  the  opposite  pin  bent 
helow  it  on  the  mandrel,  and  so  with  the  others  (Fig.  458). 


NATURAL    ROOT    AND    ARTIFICIAL    CROWN. 


667 


12.  Slip  the  crown  over  the  post,  try  occlusion,  and  with  the  post- 
chuck  bend  the  post  until  the  crown  is  properly  aligned  with  the 
teeth  ;  then  with  a  stump  corundum  wheel  No.  3  grind  the  neck  of  the 
crown  to  a  close  labial  fit  with  the  root,  fitting  only  the  portion  to  be 
concealed  by  the  gum,  leaving  narrow  gaps  at  the  sides  to  be  filled  by 
the  backing  between  crown  and  root  (Fig.  459). 

13.  Grind  the  cutting  edge  for  relation  to  the  other  teeth,  being  sure 
that  the  opposing  tooth  does  not  strike  crown,  or  post,  or  pins. 

14.  Fix  the  crown  on  post  by  pinching  the  pins  into  the  screw 
threads  of  the  post  with  special  pliers.     (Fig.  4i5  or  456). 

15.  Finally,  pack  the  backing  of  gold,  or  cement,  or  amalgam,  or 
Wood's  metal,  oi' — for  temporary  backing  while  treating  abscess — 
gutta-percha,  into  all  the  crevices  around  the  post  and  behind  and 


Fig.  454.  Fig.  455.         Fig.  456.         Fig.  457.         Fig.  458.      Fig.  459. 


under  the  pins,  and  between  the  crown  and  the  root ;  contour  and 
finish  thoroughly,  so  that  no  ledge  or  other  imperfection  can  be  found. 

Figure  460  shows  in  vertical  mid-section  an  incisor  crown  mounted  ; 
the  blackened  portions  of  the  backing  defining  the  locking-hold  of  the 
backing  on  the  post,  the  crown-pins,  and  the  root  recess. 

Figure  461  shows  in  perspective  a  cuspid  crown  ready  to  be  slipped 
over  its  post,  and  also  a  cuspid  crown  ready  for  its  post  in  the  bicuspid 
root,  which  has  its  lingual  cusp  remaining,  and  Fig.  462  shows  the 
crowns  on  their  posts  awaiting  the  contour-backing. 

In  mounting  a  crown  on  the  bicuspid  root  (Fig.  461),  the  chucks  will 
not  usually  pass  the  natural  cusp,  and  hence  both  the  drill  and  the  tap 
must  project  the  cusp's  length  in  addition  to  the  gauge  length.     Ob- 


668 


MECHANICS. 


serve  also  if  the  space  between  the  tap  and  the  cusp  is  wider  than  the 
thickness  of  a  crown-pin,  and  if  not,  cut  the  cusp  vertically  with  a  large 
fissure-burr,  so  that  the  space  shall  be  wide  enough,  before  setting  the 
post,  else  the  bent  pins  will  not  pass  between  the  post  and  cusp. 
Grind  the  rib — see  step  10 — quite  down  to  the  floor  of  the  crown  ;  take 
steps  11,  12,  and  13,  and  if  the  occlusion  necessitates  grinding  the 
crown  so  as  to  destroy  one  pair  of  pins,  invest  the  crown,  and  solder 
the  pins  at  the  lap,  taking  step  15  for  completion. 

When  it  is  desired  to  contour  the  backing  of  a  cuspid  crown  to  form 
an  inner  cusp,  or  to  adapt  a  cuspid  or  incisor  crown  for  masticating 
uses,  the  pins  may  be  twisted  together  over  the  mandrel,  and  again 
twisted  tio-htly  over  the  post,  as  in  Fig.  463  ;  but  in  some  cases  it  may  be 


Fig.  461. 


Fig.  462. 


Fig.  463. 


Fig.  464. 


Fig.  465. 


Fig.  466. 


better  to  bend  the  neck-pins,  as  in  Fig.  464,  instead  of  twisting  them. 
In  all  cases  the  bent  pins  are  to  be  pinched  quite  hard  over  the.  man- 
drel and  post,  so  that  the  serrations  of  the  pliers  will  roughen  the  pins 
to  prevent  their  being  pulled  through  the  backing,  which  should  also 
be  condensed  around  the  pins  and  post. 

If  the  root  is  not  ready  for  permanent  mounting,  use  a  tubular  post, 
or  in  the  absence  of  a  threaded  tube,  take  the  successive  steps  up  to 
13  ;  then  back  temporarily  with  wax,  rubber,  or  gutta-percha,  awaiting 
the  next  sitting,  when  the  crown  may  be  taken  off",  the  post  unscrewed, 
and  the  remedy  applied.  Thus  the  root  may  be  alternately  medicated 
and  mounted  until  ready  for  the  permanent  crown. 


NATURAL   ROOT   AND    ARTIFICIAL   CROWN, 


669 


When  the  root  is  much  decayed,  the  bottom  of  the  cone-shaped 
cavity  may  be  drilled  and  tapped  to  the  depth  of  a  sixteenth  of  an 
inch,  and  the  post,  thus  anchored,  may  be  further  secured  by  cement  in 
the  grooved  walls  of  the  cavity  and  around  the  post  (Fig.  465). 

These  crowns  afford  unusual  facility  for  mounting  by  any  of  the 
well  known  methods  of  inserting  the  post,  after  soldering  it  to  the 
crown.  They  are  also  adapted  for  use  in  celluloid  and  rubber  work, 
especially  in  cases  of  single  teeth.  The  several  long  pins,  having 
their  ends  bent  with  pliers  at  a  sharp  angle  (Fig.  466),  may  be  so 
ai'ranged  as  to  both  strengthen  the  shank  of  the  plate  and  hold  the 
crown  very  firmly  in  position. 

The  screw-posts  are  made  of  crown  metal,  an  alloy  devised  for 
the  purpose,  in  order  to  obtain  a  stiff  post  that  will  permit  the  cut- 
ting of  the  peculiar  and  extremely  accurate  thread  formed  upon  it, 
and  which  will    not   amalgamate   or  be   otherwise   affected   by  any 


Fig.  467. 


Fig.  468. 


Fig.  469. 


Fig.  470. 


Fig  471. 


backing  material  that  may  be  used.  Of  course,  platinum  or  platinum 
alloyed  with  iridium  may  be  employed  for  posts,  but  the  crown  metal 
is  in  every  way  superior. 

There  are  some  cases  of  a  class  which  has  hitherto  presented  diffi- 
culties that  may  now  be  easily  overcome  by  grinding  the  post  flat  on 
the  crown  side  after  it  has  been  set  and  bent  in  the  root  (Fig.  467),  so 
as  to  be  clear  of  the  occluding  tooth  ;  and  then  the  crown  pins  may 
be  bent  over  the  reduced  post,  the  crown  fitted  and  ground  to  clear 
the  opposing  tooth  (Fig.  468),  and  the  backing  added. 

A  similar  case,  in  which  the  opposing  tooth  and  a  proper  alignment 
require  an  oblique  bending  of  the  pins,  is  seen  in  Fig.  469,  while  the 
reverse  arrangement  of  parts  is  shown  in  Fig.  470.  The  crown  is  thus 
seen  to  be  adapted  to  a  wide  range  of  adjustments  because  its  point  of 
contact  with  the  root  is  at  the  labial  portion  of  the  neck,  on  which,  as 


670 


MECHANICS. 


Fig.  473. 


on  a  hinge,  the  crown  may  be  swung  out  or  in  (Fig.  471,  clotted  lines), 
over  an  arc  of  at  least  sixty  degrees,  at  any  point  of  which  it  may  be 
quickly  and  firmly  fixed.  The  labio-cervical  junction  is  made  just 
under  the  gingival  margin,  and  I  usually  interpose  a  thin  layer  of 
cement,  amalgana,  or  gutta-percha,  or  a  narrow  ribbon  or  several  large 
blocks  of  soft  gold ;  the  joint  always  to  be  made  smooth,  and  hid  from 
view  under  the  free  margins  of  the  gums. 

Dr.  M.  L.  Logan  has  devised  a  porcelain  crown  (Fig.  472),  with  a 
round  metal  pin  placed  in  position  before  burning 
the  tooth.  The  pin  extends  three-eighths  of  an 
inch  outside  the  crown,  which  is  provided  with  a 
basal  cavity  intended  to  be  filled  with  a  cement, 
or  other  retaining  material,  to  afibrd  additional 
support.     Fig.  473  shows  the  crown  in  position. 

Dr.  C.  M.  Richmond  has  devised  a  modified  form 
(Fig.  474)  of  the  last  described  crown,  which  con- 
sists in  making  the  pin  square  instead  of  round,  to 
prevent  the  crown  from  rotating,  and  in  forming 
an  opening  on  the  palatal  or  lingual  surface  of  the  basal  cavity,  for 
the  free  escape  of  the  filling  material  when  placing  the  crown  in 
position.     Dr.  Richmond  suggests  that  a  quick- 
FiG.  475.    setting  material,  such  as  oxyphosphate  of  zinc,  be 
used  in  the  bottom  of  the  cavity,  and  amalgam  at 
the  surface.     Fig.  475  shows  the  modified  crown 
in  position. 

Dr.  S.  D.  Rambo  has  suggested  a  method  of 
restoring  broken  crowns  of  teeth  with  pieces  of 
artificial  teeth  in  connection  with  pivots,  which 
he  describes  as  follows : — 

"  Beginning  with  a  central  incisor,  with  one- 
third  of  the  crown  broken  ofi",  as  in  Fig.  476  A, 
I  fill  the  root  with  lead  wire,  as  follows:  From  a  piece  of  sheet  lead 
I  cut  a  strip  and  pass  it  through  a  draw  plate  until  it  is  reduced  to  the 
size  of  a  medium  pin  ;  cut  the  wire  into  pieces  one  inch  long  and  roll 
one  end  to  fit  the  foramen  at  the  apex.  If,  in  passing  it  up,  I  find  that 
it  goes  through  (which  I  ascertain  from  the  pain  produced),  I  take  it 
out  and  cut  the  point  oS"  a  little,  and  try  it  again.  When  I  find  that 
it  has  closed  the  apex  exactly,  which  I  know  from  the  touch,  I  pass 
down  by  the  side  of  it  a  nerve-plugger  the  same  shape  as  the  lead 
needle  introduced,  making  room  for  another  wire,  and  so  on  until  I 
find  the  first  third  of  the  root  filled.  I  then  fill  the  middle  part  with 
gutta-percha,  cutting  the  wires  ofi"  as  far  up  as  I  can,  otherwise  the 
lead  might  discolor  the  tooth  at  the  margin  of  the  gums.     I  then  fill 


Fig 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN. 


671 


the  last  third  of  the  root  with  oxyphosphate  cement,  to  prevent  the 
tooth  from  turning  dark.  Before  introducing  the  lead  wires,  I  moisten 
them  with  phenic  acid  or  creasote.  Lead  is  less  irritating  in  the  flesh 
than  any  of  the  other  metals.  I  have  found  buckshot  in  deer  that 
had  long  since  healed  over,  with  no  sign  of  inflammation  or  ulcei's. 
For  the  reason  that  flesh  will  kindly  heal  around  lead,  I  think  it  the 
best  material  that  can  be  employed  for  filling  the  roots  of  teeth.  Next, 
drill  a  hole,  as  if  for  a  pivot,  and  shape  the  rough  edges  of  the  crown 
more  or  less  as  in  Fig.  476  a.  Select  a  plate  tooth  having  pins 
parallel  with  the  sides,  the  exact  shade  of  the  tooth  to  be  operated 
upon,  and  grind  it  to  fit  the  part  to  be  replaced.  (See  Fig.  476  b.) 
Back  the  piece  of  artificial  tooth  with  a  thin  platinum  plate,  cutting 
the  pins  off"  smoothly  with  the  backing,  and  secure  it  by  splitting  the 
heads  of  the  pins.  Then  put  the  platinum  wire  into  the  hole  drilled 
for  the  pivot,  inserting  it  loosely,  and  bending  to  such  a  shape  as  to 
touch  against  the  walls  so  that  it  may  occupy  the  same  position  when 
replaced.     Attach  the  piece  of  tooth  to  the  wire  (which  is  already  in 

Fig.  476. 


the  tooth)  with  wax,  leaving  a  space  the  thickness  of  a  00  file  between 
the  natural  and  piece  of  artificial  tooth.  Now  draw  the  wire  out  very 
carefully,  to  guard  against  displacing  the  piece  of  tooth ;  invest  in 
plaster,  and  solder  with  pure  gold.  Make  the  backing  thick  enough 
to  give  the  necessary  finish  to  the  tooth.  Next,  dry  the  hole  with  hot 
air ;  put  the  piece  of  tooth  in  its  place  with  enough  plastic  filling 
(either  gutta-percha  or  oxyphosphate)  around  the  wire  to  fill  the  inter- 
spaces; then  cut  out  the  material  in  the  joint  to  the  depth  of  two  lines, 
fill  in  with  gold,  and  finish  with  disks,  etc.  The  crown  is  now  restored 
(see  Fig.  476  c)  with  something  that  does  not  attract  so  much  atten- 
tion, which  is  more  lasting,  and  is  far  more  artistic,  with  less  fatigue 
to  patient  and  operator  than  if  it- had  been  restored  with  gold. 

Fig.  476  D  represents  a  central  incisor  having  two-thirds  of  the 
crown,  parallel  to  the  cutting  edge,  broken  ofi*.  In  a  case  of  this  kind 
fit  a  point  to  the  crown,  and  proceed  in  the  same  manner  as  described  in 
the  preceding  case.     Fig.  476  e  shows  the  piece  of  porcelain  tooth 


672 


MECHANICS. 


prepared,  and  Fig.  476  f  a  side  view  of  the  restored  crown.  All 
except  that  portion  of  the  broken  surface  of  the  natural  tooth  that  is 
not  covered  by  the  artificial  piece  must  be  covered  with  a  thin  platinum 
plate,  with  a  hole  through  it  to  permit  the  wire  to  pass.  This  is  done 
in  order  to  have  a  wall  to  flow  the  solder  against,  and  to  make  the  piece 
the  required  thickness  at  the  joint.  Cases  like  Fig.  476  A  sometimes 
require  similar  treatment.  When  there  is  plenty  of  space  on  the  palatal 
surface,  retaining  pits  may  be  made,  and  the  shape  restored  by  building 
gold  against  the  backing  of  the  artificial  tooth.  The  latter  requires 
more  time,  and  is,  perhaps,  no  better,  if  as  good  as  the  former. 

"  Many,  no  doubt,  would  cut  off"  the  remainder  of  the  crown  in  a 
case  like  that  shown  in  Fig.  476  d  and  pivot.  But  I  consider  tooth- 
structure  too  valuable  to  be  thus  lost,  to  say  nothing  of  the  difficulty 
of  making  a  joint  beneath  the  gum  so  perfectly  as  to  prevent  the  ac- 
cumulation of  vitiated  secretions  around  it.  I,  therefore,  save  all  I  can, 
not  being  particular  where  the  joint  is  made.  Another  advantage  in 
having  the  joint  at  a  distance  from  the  gum  is,  that  the  root  is  less 
liable  to  decay.  Still,  even  when  the  crown  is  entirely  lost  (see  Fig. 
476  G  and  h),  I  find  the  above  method  a  good  one  for  pivoting,  using 
gutta-percha  to  secure  the  tooth  in  position,  and  to  prevent  the  secretions 
from  entering  the  joints,  tryuming  smoothly  the  excess  of  gutta-percha 
around  the  joint. 

"Bicuspids  and  molars  (see  Figs.  477  and 
478),  having  very  large  buccal  or  approximal 
cavities  extending  into  the  grinding  surface, 
can  be  easily  managed  by  fitting  pieces  of  arti- 
ficial teeth  into  cavities.  If  the  teeth  are  dead 
the  pieces  may  be  more  perfectly  secured  by 
soldering  a  wire  and  extending  it  down  the 
root.  In  operating  on  a  superior  molar,  use  a 
long  wire  for  the  palatal  root,  and  a  shorter  one 
may  be  placed  on  the  opposite  side  as  a  brace. 
Excavate  the  material  as  described,  and  fill 
around  with  gold." 
It  remains  briefly  to  refer  to  the  application  of  vulcanite  to  the 
pivoting  of  teeth. 

The  following  method  admits  of  variations  to  suit  a  metal  pivot, 
rubber  pivot  or  the  usual  hickory  pivot.  Prepare  the  root  as  usual, 
being  careful  to  drill  the  canal  with  utmost  uniformity  and  smoothness. 
Have  a  set  of  very  smooth  aluminum  pins,  about  a  half-inch  long,  to 
suit  the  canals  made  by  diflferent-sized  drills;  select  one  which  will  fit 
accurately  into  the  root,  yet  can  be  easily  removed,  and  press  it  to  the 
bottom  of  the  canal,  letting  it  project  below  the  root  a  fourth  of  an 


Fig.  477. 


Fig.  478. 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN.  673 

inch.  Carefully  take  a  plaster  impression  of  the  root  and  two  adjoining 
teeth  in  a  small  wax  or  tin-foil  cup;  when  quite  hard,  break  it  in  the 
line  of  the  arch,  and  remove.  The  pin  may  come  with  the  plaster  or 
remain  in  the  tooth  ;  sometimes  the  break  in  the  plaster  will  be  just  at 
the  pin ;  but  when  pressed  together  the  hole  will  be  entire.  Into  this 
hole  place  the  pin,  if  yet  in  the  tooth.  Soap  this  impression  and  make, 
with  great  care,  a  model,  using  the  finest  plaster ;  when  the  plaster  has 
fully  set,  remove  the  impression  piecemeal,  so  as  not  to  injure  the 
model,  which  should  then  be  hardened  with  dilute  soluble  glass. 

The  model,  with  its  projecting  aluminum  pin,  is  now  ready  for  fitting 
and  attaching  the  tooth  ;  this  may  be  retained — 1.  Brj  a  hickory  pivot ; 
in  which  case  select  a  plate  or  rubber  tooth,  which  will  not  interfere 
with  the  pin  ;  fit  it  to  the  root,  the  front  edge  alone  touching ;  arrange 
the  wax,  and  set  in  flask  for  vulcanizing.  When  finished,  draw  the 
aluminum  pin  ;  in  the  hole  insert  a  compressed  hickory  pivot,  and  pro- 
ceed as  with  a  porcelain  pivot  tooth.  There  are  three  advantages  in 
this  kind  of  pivot  tooth  ;  it  fits  the  root  accurately,  canals  in  root  and 
tooth  are  of  same  size,  and  are  also  exactly  in  line — three  points  which 
cannot  always  be  secured  in  an  ordinary  porcelain  pivot  tooth.  If  a 
plate  tooth  is  used,  a  loop  or  hook  must  be  soldered  to  the  tooth  pins, 
passing  around  the  aluminum  pin.  2.  By  a  metallic  pivot ;  in  which 
case  fit  a  crown  to  the  root,  as  before.  If  an  aluminum  pivot  is  pre- 
ferred, the  one  already  in  the  plaster  may  be  retained,  the  projecting 
part  roughened  with  a  file,  and  the  wax  then  arranged  and  the  piece 
prepared  for  vulcanizing.  If  a  gold  pivot  is  preferred,  carefully  draw 
the  aluminum  pin  and  replace  with  a  gold  one  of  exactly  the  same 
size.  3.  By  a  vulcanite  pivot ;  in  which  case  a  plain  vulcanite  tooth 
may  be  used,  first  carefully  drawing  the  aluminum  pin ;  then  set  a 
small  wire  in  the  hole,  extending  downward  behind  the  tooth,  to 
strengthen  the  pivot.     Apply  wax  and  prepare  for  vulcanizing. 

Lining  the  root  canal  with  a  gold  cylinder,  filling  a  conical  cavity 
with  foil,  or  any  other  preliminary  preparation  of  the  root,  does  not 
modify  the  processes  just  described  ;  but,  among  the  advantages  of  the 
vulcanite  pivot  tooth  is  the  readiness  with  which  it  fits  an  irregular 
surface ;  hence,  a  root  hollowed  by  decay  need  not  be  filled,  provided 
there  is  sufficient  length  of  sound  root  for  the  canal.  Another  advan- 
tage is  the  firmness  given  to  the  close  fitting  of  the  rubber  to  the  base 
of  the  root. 

A  method  of  applying  hard  or  vulcanized  rubber  to  pivot  work  has 
•been  suggested  by  Dr.  J.  Richardson,  and  is  briefly  described  by  Dr. 
J.  E.  Dexter,  as  follows  :  "  An  ordinary  pivot  crown  is  loosely  fitted 
up  with  a  wood  peg,  which  also  fits  loosely  the  canal  in  the  root.  The 
crown  is  ground  from  before  backward  so  as  to  leave  a  space  between 

43 


674  MECHANICS. 

the  posterior  portions  of  root  and  crown.  Wax  applied  to  the  root 
and  crown  at  once  holds  the  crown  and  pivot  in  proper  relative  posi- 
tion, and  gives  an  impression  of  the  root  end.  The  whole  is  withdrawn, 
and  so  invested  in  plaster  that  the  crown,  peg  and  wax  may  be 
removed,  and  the  crown  be  capable  of  accurate  replacement  on  the 
model.  The  hole  in  the  root  and  root  model  are  now  properly  drilled 
by  the  same  drill  to  receive  a  gold  wire  pivot ;  the  latter  being  long 
enough  to  project  above  the  root  into  the  crown,  and  being  smaller 
than  the  holes  in  both  root  and  crown,  to  allow  of  vulcanite  enwrap- 
ping it  within  these  spaces.  Now  the  hole  in  the  root  model  is  packed 
with  vulcanite  gum,  the  gold  pivot  heated  and  pushed  through  the 
gum  to  its  place,  the  hole  in  the  crown  also  packed,  and  the  crown 
forced  to  its  position  on  the  model  over  the  projecting  end  of  the  gold 
pivot.  More  gum  is  packed  in  the  palatal  groove  between  root  and 
crown,  the  whole  flasked  and  vulcanized,  and  the  finished  crown  forced 
to  its  place  on  the  root,  a  few  folds  of  gold  foil  being  interposed  to  fill 
the  joint  tightly. 

"  Dr.  Richardson  also  made  vulcanite  tubes  for  pivot  sockets,  to 
replace  those  of  gold  commonly  used,  by  vulcanizing  a  layer  of  gum 
around  a  gold  wire,  which  should  afterward  form  the  pivot.  The 
wire,  being  wrapped  in  a  single  layer  of  tin  foil,  was  readily  drawn 
from  the  tube  after  vulcanizing,  the  tin  being  removed  with  muriatic 
acid.  A  proper  length  of  the  vulcanite  tube  was  inserted  in  the  root, 
either  by  force  and  a  tight  fit,  or  by  aid  of  plastic  cements,  and  the 
pivot,  vulcanized  to  a  porcelain  crown,  was  made  to  take  up  the  extra 
space  in  the  tube  caused  by  the  removal  of  the  tin  foil,  by  bending,  or 
by  splitting  and  springing  it  open." 

Also,  Dr.  H,  C.  Register's  variation  of  this  method,  which  "is  to  use 
an  ordinary  plain  rubber-tooth,  and  form  its  palatal  contour  with  vul- 
canite. Through  this  a  hole  is  drilled,  in  line  with  that  in  the  root,  the 
latter  being  filled  with  hickory  wood.  The  crown  now  being  held  in 
position,  a  drill  is  passed  through  the  hole  in  the  vulcanite  into  the 
wood  in  the  root,  and  a  gold  screw  pivot  is  passed  through  the  crown 
into  the  wood  root  socket,  holding  the  two  firmly  together.  The  details 
need  no  further  description." 

A  method  of  pivoting  a  bicuspid  is  suggested  by  Dr.  Bishop  and 
described  as  follows  by  Dr.  Dexter  :  "  The  root  being  a  first  bicuspid, 
both  canals  were  opened,  and  a  thin  wire  set  loosely  in  each,  the  pro- 
jecting ends  being  bent  together  like  a  staple  over  the  root  face. 
Gutta-percha  was  then  packed  upon  the  root  face,  around  and  under 
the  wire  staple.  A  plain  rubber  tooth  was  now  ground  to  fit,  and  held 
in  place  while  the  gutta-percha  was  continued  over  its  pins  and  shaped 
to  contour. 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN.  675 

"  The  whole  was  now  removed  together,  invested,  vulcanite  gum 
substituted  for  the  gutta-percha  and  vulcanized.  The  tooth  was  set  in 
place  with  plastics  in  the  canals  around  the  pins. 

"  This  method  appears  to  have  much  value  for  certain  cases.  Vari- 
ations of  it  may  be  noted ;  for  instance,  using  oxyphosphate,  oxy- 
chloride,  or  fossiline,  in  place  of  the  gutta-percha,  and  leaving  the 
tooth  in  place,  for  a  temporary  purpose,  instead  of  removing  and 
vulcanizing.  Also,  using  heavier  wires  of  platinum  and  iridium 
alloy  for  the  pivots,  and  springing  them  apart,  after  vulcanizing, 
so  as  to  obtain  their  spring  pressure  in  maintaining  the  tooth  in 
place." 

Banded  or  Ferruled  Pivot  Teeth. — Dr.  W.  H.  Dwindle,  in  the 
American  Journal  of  Dental  Science,  April,  1855,  was  the  first  to 
suggest  the  banded  or  ferruled  pivot  tooth  in  connection  with  crystal 
gold,  for  restoring  lost  or  fractured  crowns.  Fig.  479  represents  the 
shape  or  mould  into  which  crystal  gold  is  packed,  a  plate 
tooth  being  first  backed  with  gold,  to  which  is  soldered  a  "^'^'  P^' 
band.  The  tooth  is  fastened  to  the  root  by  a  screw  passing 
through  a  horizontal  plate  at  the  base  of  the  backing  into  the 
dentine,  and  a  somewhat  larger  screw  having  been  placed  and 
secured  in  the  pulp  canal,  with  the  free  end  projecting  into 
the  cap  on  the  crown,  gold  is  built  around  this  end  and  the 
cap  filled. 

What  may  be  more  properly  termed  a  "  cap  crown''  than  a  pivot 
tooth  was  suggested  by  Dr.  Wm.  N.  Morrison,  in  the  Missouri  Dental 
Journal,  May,  1869.  No  screws  or  pivots  are  used  in  this  method,  but 
a  cap  of  gold  is  made  in  the  form  of  a  tooth  crown,  by  being  swaged 
on  a  model  or  die  of  a  natural  tooth,  its  sides  encircling  the  root,  and 
extending  under  the  gum  to  the  edge  of  the  alveolar  process.  A  bar 
is  soldered  across  the  inside  of  the  cap,  to  afford  a  support  for  the  oxy- 
chloride  of  zinc  (the  oxyphosphate  will  answer  also).  The  root  is 
then  prepared  for  the  reception  of  the  cap,  which  is  filled  with  the  zinc 
preparation  and  pressed  into  place  on  the  root.  Dr.  B.  Beers,  in  1873, 
suggested  a  method  of  forming  a  gold  crown  from  a  flat  strip  of  gold 
by  stamping  it  in  the  centre  on  a  block  of  lead,  with  a  punch.  The 
gold  is  then  annealed,  and  the  two  ends  bent  around  the  tooth  (the 
stamped  surface  representing  the  labial  surface  of  a  front  tooth),  and 
these  ends  soldered  together.  The  "  bite"  is  then  adjusted  by  means 
of  a  half-round  file,  so  that  the  tooth  articulates  properly  with  its  an- 
tagonists. A  thick  flat  piece  of  gold  is  then  bent  to  suit  the  form  of 
tooth  required  and  soldered  on  the  top  of  the  gold  crown,  which  is 
fastened  to  the  root  by  inserting  headed  gold  screws  into  the  canal  and 
then  filling  the  cap  with  oxychloride  of  zinc,  when  it  is  forced  over  the 


676 


MECHANICS. 


root  to  its  proper  place.     Fig.  480  represents  Dr.  Beers'  crowns  and 
method  of  attachment  to  the  roots  of  teeth. 

Dr.  E.  S.  Talbot  has  improved  upon  the  method  of  Dr.  Beers,  by  a 
band  fitted  to  the  root,  and  extending  to  the  alveolus,  across  the  inside 
of  which  a  partition  or  floor  of  gold  is  soldered.  In  this  floor  holes 
are  made  opposite  the  pulp  canals  underneath.     Wires  are  loosely 

Fig.  480. 


Fig.  481. 


inserted  in  these  canals,  and  the  space  in  the  band  beneath  the  floor  is 
filled  with  gutta-percha  or  one  of  the  zinc  preparations,  and  the  band 
forced  into  position  on  the  root,  the  wires  projecting  through  the  holes 
in  the  floor.  After  the  gutta-percha  or  cement  has  become  hard,  the 
wires  are  drawn  out,  and  headed  screws  are  substi- 
tuted, which  fasten  the  band  or  crown  to  the  root. 
The  work  is  completed  by  filling  the  band  with  gold, 
or  by  swaging  a  gold  crown  or  cap,  which  is  slipped 
over  or  within  the  edge  of  the  band  encircling  the 
root,  the  cap  being  previously  filled  with  cement. 
Fig.  481  represents  Dr.  Talbot's  method. 
Dr.  C  M.  Richmond's  method  of  making  what  are 
known  as  the  "Richmond  Crowns"  is  as  follows: 
This  crown  consists  of  a  close-fitting  band  or  ferrule 
of  coin  gold  plate,  to  which  a  cap  or  surface,  corresponding  to  the 
grinding  surface  of  the  class  of  tooth  it  is  designed  to  crown,  is  soldered. 
The  root  is  prepared  by  making  the  exposed  surface  flat,  by  means  of  the 
file  or  corundum  disk.  A  strip  of  gold  plate,  about  No.  27  American 
gauge,  is  then  cut,  of  such  a  width  as  will  extend  from  the  alveolar 
process  to  a  height  sufficient  to  give  the  proj)er  length  of  gold  crown. 
To  determine  the  proper  width  of  the  strip  or  ferrule,  a  pattern  of  tin 
or  sheet  lead,  adapted  to  the  tooth,  may  be  used.  The  strip  of  gold 
plate  is  then  bent  with  the  pliers,  and  filed  to  the  proper  form,  and 
the  overlapping  ends  soldered  together,  the  ferrule  being  made  slightly 
smaller  than  the  root  it  is  to  encircle,  so  as  to  secure  a  tight  fit.  After 
the  band  or  ferrule  is  completed,  it  is  capped  by  a  piece  of  plate  large 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN.  677 

enough  to  cover  the  crown  end,  and  the  two  soldered  together  and 
properly  finished  by  smoothing  the  sharp  edges  with  a  file  and  burn- 
isher     The  cap  or  crown  is  then  adapted  to  the  festooned  margin  of 
the  gum  and  septa,  by  filing  the  approximal  edges  concave.     The 
mav^m  of  the  gold  crown,  where  it  comes  in  contact  with  the  neck  _ol 
the  root,  is  slightly  beveled  from  the  outside,  in  order  to  make  a  thin 
edge,  which  will  adapt  itself  to  the  surface  of  the  neck  under  the 
pressure  necessary  to  force  the  crown  to  its  place  on  the  root.     The 
crown  is  then  forced  over  the  root,  and  the  position  of  the  artificial 
cusps  yet  to  be  made  determined  by  the  antagonism  of  the  opposing 
teeth      Small,  flattened  buttons,  made  by  melting  scraps  of  plate,  and 
slio-hUy  flattening  them  by  blows  with  a  hammer,  are  soldered  on  the 
grfndin.  surface  of  the  gold  crown,  which  is  filled  and  invested  during 
the  soldering  process  with  moistened  sand,  to  which  is  added  a  little 
plaster      After  thus  attaching  the  cusps  and  contouring  the  grinding 
surface,  the  gold  crown  is  ready  to  be  adjusted  to  the  root.     A  small 
hole  is  first  drilled  through  the  side  or  top  of  the  crown,  to  allow  the 
surplus  cement,  by  which  the  crown  is  secured,  to  escape.     The  con- 
cavity of  the  crown  is  then  filled  with  either  the  oxychloride  or  oxy- 
phosphate  of  zinc,  mixed  somewhat  thinner  than  for  a  temporary 
filling,  and  the  crown  forced  over  the  root,  and  the  patient  directed  to 
bite  upon  it,  in  order  to  secure  the  proper  occlusion  of  the  teeth.    The 
crown  is  then  firmly  held  in  place  until  the  cement  has  hardened,  when 
the  small  hole  through  which  the  surplus  has  escaped  can  be  filled 
with  gold.     Any  slight  defect  in  the  articulation  can  be  remedied  by 
grinding  with  corundum  points.  _ 

The  method  of  Dr.  H.  W.  F.  Buttner  is  a  combination  of  the  terruie, 
or  band  encircling  the  root,  and  a  central  pivot,  and  is  described  as 
follows  by  Dr.  J.  E.  Dexter :— 

■  "A  special  set  of  instruments  is  used  in  this  V^^^'f-^"^)'''^'' 
preparing  the  root  are  drills,  reamers  and  trephines  (Fig  482  be  d).  The 
drin  bores  out  the  root  canal.  The  reamer  cuts  the  face  of  the  root 
level,  being  guided  by  a  central  pin.  The  trephine  turns  the  neck 
truly  cylindrical  for  a  certain  distance  up  or  down  its  sides,  b^ng  ako 
guided  by  a  centre  pin.  The  root,  thus  prepared,  is  shown  m  Fig.  48o. 
The  drill,  reamer  and  trephine  are  in  various  and  exactly  correspond- 

'"-riteel  wire  is  now  placed  in  the  root,  projecting  half  an  inch. 
An  impression  is  now  taken,  the  wire  projecting  through  it ;  a  cup 
with  an  opening  over  the  root  being  used  for  that  purpose.  The  ^^•lre 
is  withdrawn  carefully  before  removal  of  the  impression  from  the 
mouth  but  is  afterward  replaced.  Over  it,  on  the  impression  is  now 
Tpped  that  one  of  a  set  of  brass  root  models  (Fig.  482  a),  which  cor- 


078 


MECHANICS. 


responds  to  the  drill  and  trephine  used,  and  the  model  is  then  made, 
and  holds  the  brass  root  model  in  its  place,  with  the  wire  projecting. 
The  latter  is  now  removed,  and  plaster  cut  from  around  the  root  model 
to  a  depth  sufficient  to  accommodate  the  cap  which  is  to  follow.  This 
is  of  gold,  struck  out  of  the  solid,  on  that  one  of  the  accompanying 
steel  dies  which  accords  with  the  trephine  and  root  model  used.  It 
also  has  a  central  pin,  to  correspond  with  the  drill  which  enlarged  the 
root  canal  (Fig.  483).  This  cap  is  set  on  the  root  model,  and  a  plain 
plate  tooth,  ground  hollow  on  the  inner  surface,  to  cover  the  outer  wall 
of  the  gold  cap,  is  backed,  and  soldered  in  place  on  the  cap — of  course, 
after  removal  from  the  brass  •  root  model — the  solder  forming  the 
palatal  contour.  The  whole  is  now  polished,  placed  on  the  root,  and 
driven  home  with  a  mallet  (Fig.  484). 

"The  perfectly  accurate  fitting  of  this  operation  is  secured,  beyond 
cavil,  by  the  set  of  drills,  reamers,  trephines,  dies  and  root  models. 


Fig.  482. 

he  d 


n^_ .  \v^ 


^ 


Fig.  483. 


Fig.  484. 


with  Avhich  it  is  performed.  Probably — indeed,  almost  certainly^- 
this  is  the  strongest  method  of  attachment  of  artificial  crowns  to 
natural  roots  which  can  be  devised.  Indeed,  the  only  thing  break- 
able about  any  given  case  of  this  method  seems  to  be  the  porcelain 
crown  or  face.  The  end  and  interior  of  the  root,  also,  are  absolutely 
preserved  from  moisture  for,  at  least,  a  very  long  time." 

Artificial  Crowns  Attached  to  Natural  Teeth  without  Plates  or  Clasps. — 
These  operations  are  of  comparatively  recent  date,  and  are  generally 
known  as  "  bridge  work"  or  "  grafting,"  which  is  simply  an  extension 
of  artificial  crowns  over  spaces  made  by  the  loss  of  natural  teeth.  The 
credit  of  first  inserting  artificial  crowns  to  adjoining  natural  teeth,  by 
fillings  of  cohesive  gold  foil,  is  due  to  Dr.  B.  J.  Bing,  who  describes 
his  method  as  follows : — 

"In  the  case  of  inserting  a  central  incisor,  a  cavity  must  be  made  in 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN. 


679 


the  palatine  depression  of  the  adjoining  central,  and  also  the  lateral, 
and  one  in  the  approxinial  surface  of  either  of  these  teeth,  about  the 
place  where  we  usually  find  decay  on  these  surfaces.  An  impression 
is  then  taken  which  will  show  these  cavities,  and  a  gum  or  plain  plate 
tooth  carefully  fitted  and  backed  with  gold,  observing  the  precaution 
of  allowing  a  small  point  of  the  backing  to  extend  into  the  approximal 
cavity.  Two  little  griffes  (bars)  are  then  soldered  to  the  base  of  the 
backing,  the  ends  of  which  are  carefully  plugged  into  the  palatine 
cavities  with  gold  foil,  in  such  a  manner  as  will  tend  to  draw  these 
teeth  very  slightly  together." 

Dr.  W.  F.  Litch  has  modified  Dr.  Bing's  method,  an  abridged 
description  of  which,  by  Dr.  Dexter,  is  as  follows: — 

"  Supposing  a  left  upper  lateral  to  be  inserted :  Take  an  accurate 
impression  of  the  parts  (canine  and  central,  and  gum  between),  and 
make  metallic  dies  from  the  model.  Swage  gold  or  platinum  plates 
to  very  exactly  fit  the  palato-approximal  surfaces  of  the  canine  and 
central.     Fit  into  the  interspace  a  plain  plate  lateral  incisor,  slightly 


Fig.  485. 


wider  than  the  space  to  be  filled,  beveling  and  grinding  the  sides 
posteriorly,  so  that  the  tooth  cannot  be  forced  backward  between  its 
neighbors;  the  neck  fitting  accurately,  but  lightly,  upon  the  gum. 
Back  the  tooth  with  gold.  Place  the  prepared  tooth  and  the  struck 
plates  upon  a  perfect  model  of  the  parts,  and  adjust  the  tooth  backing 
accurately  to  the  plates  on  each  side.  Cement  together  with  shellac 
or  other  resinous  cement;  remove  and  complete  the  final  adjustment 
in  the  mouth.  Invest,  and  solder  the  tooth  and  plates  together  in 
their  exact  relative  positions,  observing  to  accumulate  a  large  portion 
of  solder  over  the  joints  (Fig.  485).  The  apparatus,  if  now  placed 
in  the  mouth,  will  be  found  self-supporting  against  any  force  except 
the  perpendicular ;  for  it  cannot  be  forced  backward  into  the  mouth, 
owing  to  the  extra  width  of  the  lateral ;  nor  forward  out  of  the 
mouth,  owing  to  the  wings  or  plates  extending  over  the  backs  of 
the  neighboring  teeth;  nor  upward  toward  the  gum,  owing  both  to 
the  porcelain  tooth  resting  thereon,  and  to  the   converging  planes 


680 


MECHANICS. 


of  the  plates  or  wings  and  the  postero-approximal  surfaces  of  the 
artificial  tooth. 

The  methods  of  final  attachment  are  two,  depending  upon  the 
case:  1.  If  one  of  the  neighboring  teeth  is  devitalized,  attaching 
a  pivot  to  the  plate  on  that  tooth  and  inserting  it  with  gutta- 
percha, the  plates  themselves  being  covered  with  a  film  of  the  same 
substance  on  their  dental  aspects  (Fig.  486).  2.  If  the  teeth  are 
both  alive,  a  modification  of  Bing's  plan  of  filling,  performed  as 
follows : — 

The  denture  being  constructed  as  before  described,  and  polished, 
drill  a  cavity  in  the  centre  of  the  palatal  face  of  each  tooth  covered 
by  the  plates,  slightly  larger  in  diameter  than  the  head  of  the  pin  in 
an  ordinary  rubber  tooth,  no  deeper  than  the  enamel,  and  undercut 
(Fig.  487  b).  To  each  of  these  openings  fit  a  platinum  one-headed 
rivet,  the  head  being  very  thin  and  perfectly  flat  on  each  side.  Split 
the  shanks  of  the  rivets  nearly  to  the   head   (Fig.  487  a).     Make 


Fig.  48 


Fig.  489. 


openings  in  the  plates  to  exactly  correspond  with  those  in  the  teeth, 
and  countersink  them  deeply  on  their  palatal  aspect.  Place  the  gutta- 
percha on  the  dental  surfaces  of  the  plates,  as  described,  and  press  the 
denture  to  its  place  in  the  mouth.  When  the  cement  is  cooled  and 
hard,  remove  that  portion  pressed  into  the  holes  in  the  plates  and 
teeth,  pass  the  rivet  heads  through  the  holes  in  the  plates  to  their  seats 
in  the  tooth  cavities,  and  fill  them  in  position  with  gold.  When  the 
fillings  have  reached  the  level  of  the  tooth  surfaces,  spring  open  the 
split  rivet  shanks  and  continue  packing  gold  around  and  between  the 
separated  parts  and  into  the  couutei'sinks  in  the  plates  until  flush 
with  the  plate  surfaces.  Cut  ofi"  the  surplus  pivot  shanks  and  finish 
(Fig.  487). 

Dr.  Litch's  method  can  also  be  adapted  to  the  restoration  of  fractured 
angles  of  incisor  teeth,  as  shown  in  Figs.  488  and  489,  and  w^hich  need 
no  further  description. 


NATURAL    ROOT   AND    ARTIFICIAL   CROWN. 


681 


Fig.  490  represents  a  case  of  two  bicuspid  crowns  secured  to  oue 
root  and  two  adjoining  teeth. 

The  hate  Dr.  M.  W.  Webb  ^^«-  ^9^' 

also  modified  the  methods  of 
Dr.  Bing  by  forming  an  un- 
dercut groove  in  the  porcelain 
crown  in  each  side  and  along 
the  cutting  edge,  and  filling 
gold  foil  solidly  in  the  groove 
and  slightly  over  the  cutting 
edge,  to  make  the  porcelain 
crown  more  secure  than  the 
platinum  pins  hold  it,  and  to 
protect  the  edge  from  the 
occlusion  of  the  lower  teeth  ; 
also  to  build  the  crown  into  the  approximal  surfaces  only. 

Dr.  Webb  also  described  a  method  by  which  a  crown  without  plate 
or  clasps  and  where  no  root  remains  can  be  inserted  :  "  After  suitably 
forming  the  cavities  in  the  proximate  wall  of  each  tooth  next  the  space 
left  by  the  loss  of  the  one  that  had  been  extracted,  a  plain  porcelain 
crown  was  fitted  to  the  place  and  backed  with  gold  plate.  A  portion 
of  the  backing  extended  about  one  and  a  half  lines  from  each  side  of 
the  crown  for  insertion  in  the  cavities  prepared  in  the  adjoining  teeth, 
and  to  these  parts  a  gold  wire  was  soldered  to  fit  into  the  pulp  chambers 
of  the  adjoining  teeth.  A  small  gold  plate  was  then  formed  to  fit  upon 
the  gum,  .covering  as  much  space  as  was  taken  up  by  the  neck  of  the 
natural  tooth.  When  the  backing  was  riveted  to  the  pins  in  the 
crown  and  this  placed  in  position,  and  while  the  whole  rested  on  the 
small  plate  upon  the  gum,  the  backing  and  plate  were  so  secured  by 
wax  that  they  could  be  removed  intact,  and  soldered.  Each  extended 
side  of  the  backing  and  the  surface  of  the  wire  was  barbed,  so  that  the 
gold  foil  would  the  better  secure  the  crown  when  filled  into  every  part. 
The  crown  with  the  gold  attachments  being  ready  for  insertion,  oxy- 
chloride  of  zinc  (or  oxyphosphate)  was  placed  in  the  pulp  chambers 
of  the  adjoining  teeth  and  the  crown  at  once  pressed  to  place.  When 
the  cement  had  hardened,  a  portion  of  it  was  cut  away,  so  as  to  make 
proper  anchorage  for  light,  cohesive  gold  foil,  which  was  impacted  in 
small  pieces  around  part  of  the  wire  and  that  portion  of  the  plate  ex- 
tending into  the  cavities,  and  the  crown  was  then  secured." 

To  avoid  any  danger  of  the  porcelain  crown  being  broken  from  the 
platinum  pins,  Dr., Webb  suggested  that  a  groove  be  cut  in  each  side, 
and  along  the  cutting  edge  of  this  crown  (Fig.  491  d),  so  that  gold 
foil  may  be  impacted  into  it  by  means  of  a  fine-edged  corundum  disk, 


682 


MECHANICS. 


after  a  heavy  backing  of  gold  plate  and  the  wire  have  been  fixed  in 
place  and  soldered  (Fig.  492,  a).  Into  this  groove  the  wire  to  connect 
the  artificial  crown  with  the  natural  teeth  is  to  be  placed  (Fig.  491  a). 
When  the  operation  of  contouring  the  palatal  surface  of  the  crown 
with  gold  foil  is  completed,  the  case  represents  the  appearance  shown 
by  Fig.  493. 


Fig.  493. 


Fig.   494. 


Dr.  Webb  also  made  use  of  a  stout  wire  (iSTo.  13),  with  a  screw 
thread  cut  upon  one  end,  for  insertion  into  a  devitalized  tooth,  and  bent 

to  receive  the  porcelain  crown  which  was 
soldered  to  its  free  end,  the  wire  being 
secured  in  place  in  the  natural  tooth  by 
filling  around  it  with  gold  foil  (Fig.  494). 
Figs.  495,  496  and  497,  show  an  exten- 
sive operation  performed  by  Dr.  M.  W. 
Webb,  in  w'hich  he  made  use  of  gold  wire 
(No.  13)  for  bridging  a  lateral  incisor,  the 
natural  tooth  having  been  lost,  and  also 
the  crown  of  the  left  cuspid,  and  disinte- 
gration had  taken  place  in  many  of  the  teeth,  and  the  front  teeth 
abraded  to  the  dentine.  Fig.  495  shows  the  case  as  prepared  for 
filling,  with  the  artificial  crown  attached  to  the  gold  wire  in  position, 
and  gold  screws  inserted  in  the  pulp  chamber  of  the  cuspid  and 
bicuspid  teeth. 

Fig.  496  shows  the  labial  contour  of  each  crown  after  the  lost 
portions  were  restored  with  gold  foil.  Fig.  497  shows  the  finished 
case. 

Dr.  H.  C.  Register  has  devised  the  following  method,  which,  in  the 
event  of  a  porcelain  crown  being  broken,  possesses  the  advantage  of 
allowing  the  place  to  be  filled  by  a  new  crown  without  disturbing  the 


NATURAL   ROOT   AND   ARTIFICIAL   CROWN. 
Fig.  495. 


683 


Fig.  496. 


Fig.  497. 


Finished  case— a,  6,  d,  f,  g  and  h,  pulpless  teeth ;  g,  whole  crown  restored  with  gold  ;  a,  f, 
and  h,  almost  entire  gold  crowns;  the  teeth  6  and  d  support  the  gold  crown  faced  with 
porcelain,  c,  and  fully  one-fourth  of  the  crown  of  each  of  these  is  restored  with  gold,  as 
is  also  that  of  e,  the  pulp  of  which  is  living. 


684 


MECHANICS. 


main  appliance.     The  following  concise  description  of  this  method  is 
by  Dr.  Dexter  : — 

"Taking  a  typical  case  (Fig.  498),  a  rim  or  saddle  of  gold,  platinum, 
or  iridinized  platinum  is  struck  to  fit  the  spaces  between  the  teeth  a 


and  B.  To  this  are  attached  bars,  x,  Fig.  500,  to  enter  the  fillings  at 
z,  z  (Fig.  499).  Posts  or  pivots  (d,  Fig.  500)  are  soldered  upon  this 
saddle  where  the  artificial  teeth  are  to  be  placed,  their  free  ends  being 


Fig.  499. 

A\^  *    all  I 


#  \m:. 


m 


<:^.    Z 


^      ^ 


Fig.  500. 


munismD  !^m 


^^'^f^^mW 


threaded  to  carry  the  nut  e.  Hollow  crowns,  countersunk  for  the  nut 
at  G,  and  having  the  necks  ground  to  reach  over  the  saddle  and  press 
upon  the  gum,  are  fitted  over  each  post.  Amalgam  is  used  to  fill  in 
the  space  between  the  post  and  the  tooth-wall,  as  in  a  Bonwill  setting, 


NATUR'AL,   ROOT   AND   ARTIFICIAL   CROWJST. 


685 


and  the  crowns  are  drawn  to  place  and  held  with  the  nut.  The  saddle 
is  fixed  in  its  place  in  the  mouth,  before  the  crowns  are  finally  attached, 
by  filling  into  the  cavities  z  the  bars  x  x." 

Dr.  J.  L.  Williams  suggests  the  following  methods  for  the  single 
crown  and  for  "  bridge  work,"  which  he  describes  as  follows : — 

"  It  consists  essentially  of  three  parts  :  a  square  pin  of  platinum  and 
iridium  which  enters  the  enlarged  pulp  canal,  a  cap  of  gold,  and  the 
porcelain  face,  which  is  the  ordinary  plate  tooth. 

"  This  crown  is  made  in  the  following  manner  :  After  the  end  of  the 
root  is  made  perfectly  smooth  with  corundum  wheels  and  properly 
shaped  scalers,  a  gold  ferrule  or  band  is  fitted  around  it.  If  it  is  de- 
sirable that  this  band  should  be  entirely  concealed,  the  labial  surface 
of  the  root  should  be  beveled  a  little  above  the  margin  of  the  gum,  and 
after  the  band  has  been  soldered  it  may  be  placed  in  position,  and  the 
line  of  contour  of  the  margin  of  the  gum  marked  upon  the  front  of  the 
band.  The  proper  bevel  can  then  be  cut  and  the  edges  squared  upon 
a  corundum  wheel,  leaving  the  lingual  portion  of  the  band  a  little 


Fig.  501. 


longer  than  the  front.  Pure  gold,  rolled  to  No.  34  of  the  standard 
gauge  (American),  is  used  for  soldering  upon  the  beveled  surfaces, 
thus  making  a  closed  cap  for  the  end  of  the  root.  A  suitable  tooth  is 
now  selected  and  backed  with  pure  platinum  or  pure  gold.  The  cer- 
vical end  of  the  tooth  is  then'  ground  to  the  proper  position  on  the 
front  bevel  of  the  cap,  all  of  the  fitting  being  done  while  the  cap  is  in 
position  on  the  root. 

After  the  fitting  is  completed  the  cap  is  removed  and  the  tooth 
attached  by  strong  resin  wax  and  again  placed  in  position  while  the 
wax  is  warm.  Any  slight  change  in  position  which  is  necessary  can 
then  be  easily  made.  The  tooth  and  cap  are  now  removed  together, 
invested,  and  united  at  the  back  by  solder.  It  is  well  to  use  a  solder 
for  the  cap  with  a  higher  melting  point  than  that  used  for  the  backing, 
as  it  obviates  the  danger  of  unsoldering  the  band  when  the  backing  is 
flowed  on.  After  finishing  and  polishing  the  work,  the  end  of  the  root 
is  made  perfectly  dry,  a  sufiicient  quantity  of  oxyphosphate  cement, 


686 


MECHANICS. 


mixed  somewhat  thinner  than  for  filling  purposes,  is  placed  in  the 
enlarged  pulp  canal  and  also  in  the  cap.  The  crown  is  then  carried  to 
place  with  firm,  steady  pressure,  and  held  a  few  minutes  until  the 
cement  is  sufliciently  hard  to  prevent  displacement.  The  surplus 
cement  which  has  oozed  out  around  the  band  should  be  carefully 
removed  and  the  work  is  then  completed. 

Dr.  Williams'    method   can    be   applied  to   "  bridge  work,"  as  the 
following  Figs.  502,  503,  and  504  will  show. 


Fig.  502. 


Fig.  503. 


Fig.  505. 


Fig.  504. 


Fig.  506. 


In  this  method,  special 
crowns,  Figs.  505  and  606,  for 
molars  and  bicuspids  with 
porcelain  faces,  are  made, 
Avhich  are  backed  with  gold 
or  platinum  and  the  tips 
ground  squarely  ofi".  Zinc 
pattern  dies  are  made  from 
the  grinding  surfaces  of  mo- 
lars and  bicuspids,  to  be  used 
for  swaging  from  pure  gold  a 
tip  or  cap  for  the  protection 


EEFINING  AND  ALLOYING  GOLD.  687 

of  the  porcelain  face.  The  concave  surface  of  these  tips  is  filled  by- 
melting  coin  gold  into  them,  and  this  surface  is  then  ground  smooth 
and  fitted  to  the  squared  surface  of  the  porcelain  face  and  waxed  in 
position.  Triangular  pieces  of  platinum  are  then  cut  of  the  proper 
size  to  fit  the  sides  of  the  tooth,  waxed  in  position,  and  the  whole 
invested,  leaving  the  back  open,  which  is  filled  with  coin  gold. 

In  concluding  the  subject  of  artificial  crowns  attached  to  natural 
roots  and  teeth,  it  remains  only  to  briefly  refer  to  the  advantages  and 
disadvantages  of  each  method.  As  regards  what  is  strictly  pivot  work, 
all  methods  are  objectionable  in  which  the  exposed  surface  of  the  root 
is  not  protected  from  such  agents  as  disintegrate  tooth  structure  ;  as 
regards  the  ferrule  or  band  ci'own,  such  work  is  objectionable  where  it 
causes  irritation  of  the  gum  and  periosteal  tissues,  or  permits  of  the 
disintegration  of  the  supporting  roots  or  teeth,  or  is  temporary  in  its 
nature,  on  account  of  the  use  of  the  plastic  preparations  in  connection 
with  it ;  and  lastly,  all  "  bridge"  or  "  graft"  work  is  objectionable 
where  it  cannot  be  kept  perfectly  clean  and  free  from  accumulations 
of  fluid  and  other  substances  beneath  it,  and  where  it  cannot  be 
repaired  in  case  of  accident  without  breaking  up  the  entire  appliance. 
The  effects  of  thermal  changes  on  tooth  tissues  when  brought  directly 
in  contact  with  large  masses  of  metal ;  and  the  exceedingly  frail  nature 
of  many  of  the  porcelain  crowns  and  facings  required  by  some  of  the 
methods  in  use,  should  also  be  considered. 


CHAPTER  VI. 


MANNER   OF    REFINING   AND    ALLOYING   GOLD,    AND   CALCULATING 

ITS   FINENESS. 

GOLD  is  the  best  metal,  and  for  general  use  the  best  material  that 
can  be  used  for  the  attachment  of  artificial  teeth.  When  used  of 
proper  fineness,  it  resists  the  most  acrid  secretions  of  the  mouth,  and 
undergoes,  during  long  years  of  use,  no  change  in  its  strength,  form,  or 
texture.  Other  metals  and  materials  have  a  special  utility,  but  none 
have  so  wide  a  range  of  usefulness,  and  none  can  take  the  place  which 
this  royal  metal  holds  in  dental  prosthetics. 

Although  the  manner  of  refining,  alloying  and  manufacturing  gold 
into  plate,  solder,  etc.,  may  not,  perhaps,  be  regarded  as  coming 
properly  within  the  province  of  the  dentist,  yet,  as  he  often  experiences 
great  difficulty  in  procuring  them  of  the  right  quality,  a  brief  descrip- 
tion of  these  several  processes  is  necessary.   Especially  is  this  necessary. 


688  MECHANICS. 

since  the  dental  depots  seldom  keep  on  hand  any  gold  plate  finer  than 
eighteen  carats.  This  we  consider  discreditable  to  the  profession  which 
calls  for  so  inferior  a  quality  of  metal,  rather  than  to  those  whose 
business  is  to  supply  their  demands.  Twenty-carat  plate  can  as  readily 
be  kept  on  hand  by  manufacturers  as  twenty-four  carat  foil.  Moreover, 
some  practitioners  are  so  situated  that  they  cannot  use  gold  plate, 
unless  they  know  how  to  prepare  it  from  coin. 

Gold  in  its  pure  state,  free  from  alloy,  is  too  soft  and  yielding  to  serve 
as  a  suitable  support  for  artificial  teeth  ;  but  if  it  contains  too  much  or 
an  improper  alloy,  it  will  become  tarnished  by  the  secretions  of  the 
mouth,  rendered  too  brittle  for  service,  through  those  molecular 
changes  which  take  place,  with  greater  or  less  rapidity,  if  the  plate  is 
less  than  twenty  carats  fine.  It  is,  therefore,  of  the  utmost  importance 
that  the  gold  used  in  connection  with  artificial  teeth  should  be  of  the 
proper  fineness,  and  possessed  of  the  requisite  malleability.  To  secure 
these  qualities,  it  is  necessary  to  know  the  kind  and  quantity  of  metal 
with  which  to  alloy  it  before  it  is  made  into  plate  or  other  forms 
necessary  for  the  purposes  for  which  it  is  to  be  employed. 

Gold  clippings,  filings  and  other  scraps  and  parts  of  old  gold  pieces, 
as  found  in  the  laboratory,  are  apt  to  become  mixed  with  base  metals, 
such  as  iron  from  the  wearing  of  files,  and  occasionally,  small  particles 
of  lead,  tin,  or  zinc.  If  these  are  melted  with  and  permitted  to  remain 
in  the  gold,  they  will  destroy  its  ductility,  and  render  it  unfit  for  use. 
Iron,  less  objectionable  than  the  lead  or  tin,  may  always  be  removed 
with  a  magnet  before  the  gold  is  melted  ;  but  to  free  it  perfectly  from 
the  others,  it  will  sometimes  be  necessary  to  refine  it  in  the  manner 
presently  to  be  described.  A  two-thousandth  part  of  tin  or  lead 
destroys  the  ductility  of  gold,  and  even  exposure  to  the  fumes  of  red- 
hot  tin  or  lead  renders  it  exceedingly  hard  and  brittle.  Antimony,  or 
bismuth,  when  mixed  with  gold,  exerts  upon  it  a  very  similar  effect. 
So  marked  is  the  influence  of  antimony  in  injuring  one  of  the  most 
valuable  properties  of  gold,  that  its  original  name  regulus  (little  king)^ 
by  which  it  is  best  known  in  commerce,  was  given  in  view  of  this  con- 
trolling effect  upon  the  king  of  metals.  It  is  of  the  utmost  importance 
to  bear  in  mind  the  action  of  minute  quantities  of  these  four  metals, 
so  much  used  in  the  laboratory,  upon  gold,  platina  and  silver. 

Platina,  united  with  gold  in  certain  proportions,  has  the  effect  of 
hardening  the  latter  metal  and  making  it  very  elastic,  but  does  not 
materially  affect  its  ductility.  The  affinity  of  the  alloy  for  oxygen, 
however,  is  so  great  that  it  is  readily  acted  on  by  nitric  acid.  The 
acids  of  the  mouth  will  often  make  this  alloy  very  brittle.  But  for  this, 
the  two  metals,  combined  in  the  proportion  of  fifteen  parts  of  gold  to  one 
of  platina,  would  form  an  exceedingly  useful  alloy  for  the  construction 


EEFINING   AND   ALLOYING   GOLD.  689 

of  spiral  springs.  That  a  combination  of  two  metals  should  be  thus 
easily  acted  on  by  an  agent  incapable  of  acting  on  either  when  in  a 
separate  state,  may  appear  somewhat  remarkable,  but  it  is,  neverthe- 
less, true.  We  have  in  the  effect  of  platina  upon  steel  an  analogous 
case.  It  makes  the  steel  exceedingly  hard  and  fine-grained ;  but 
although  itself  totally  insensible  to  the  action  of  oxygen,  when  alloyed 
in  minute  quantity  with  steel,  it  causes  this  latter  metal  to  oxidize  with 
such  readiness  as  to  make  it  unfit  for  use. 

Hence  may  be  seen  the  fallacy  of  the  idea  entertained  by  many  that 
because  platina  is  a  more  indestructible  metal  than  silver  or  copper,  it 
must  necessarily  make  a  purer  plate.  The  properties  of  alloys  are,  in 
fact,  so  often  and  so  widely  different  from  those  of  their  component 
metals  that  they  can  be  ascertained  only  by  experiment.  Of  the  three 
metals,  platina,  silver  and  copper,  speculative  theory  might  select  the 
first  and  purest  as  the  best  alloy  for  gold  ;  whereas  actual  experience 
demonstrates  that  copper,  itself  the  most  injurious  to  the  mouth, 
imparts  most  perfectly  to  gold,  if  kept  within  proper  limits,  those 
qualities  which  are  required  in  a  dental  plate. 

In  view,  then,  of  the  importance  of  having  gold  which  is  to  be  placed 
in  the  mouth  of  the  right  quality,  every  dentist  who  has  connected 
with  his  practice  a  mechanical  laboratory  should  have  the  necessary 
fixtures  for  melting  and  working  this  metal  into  the  various  forms 
required  for  dental  purposes.  The  principal  of  these  are,  a  small 
furnace,  with  crucibles  and  tongs,  ingot-moulds,  an  anvil  and  ham- 
mers, and  a  rolling  mill ;  a  plate  gauge,  draw  plate,  and  bench  vise  ; 
fluxing  and  refining  chemicals,  etc. 

REFINING    GOLD. 

It  is  not  our  intention,  in  describing  the  manner  of  refining  gold, 
to  enter  into  a  minute  detail  of  the  various  methods  employed  for 
assaying  or  refining  this  metal,  but  to  point  out,  as  briefly  as  possible, 
the  manner  of  separating  it  from  the  several  metals  with  which  it  is 
most  frequently  combined  in  the  dentist's  laboratory. 

The  method  usually  employed  by  assayers  for  separating  gold  from 
silver  is  to  roll  the  alloy  out  into  very  thin  plates,  and  put  it  in  nitric 
acid ;  this  will  dissolve  most  of  the  silver,  and  leave  the  gold  behind 
in  the  form  of  brown  plates,  scales  or  powder,  which,  after  being 
thoroughly  washed,  is  put  into  a  crucible  with  borax  and  melted  dow^n 
into  an  ingot  of  pure  gold.  But  this  method  will  not  succeed,  unless 
the  quantity  of  silver  be  equal  to  two  or  three  times  that  of  the  gold  ; 
for  the  nitric  acid,  which  acts  only  upon  the  silver  (and  copper),  cannot 
eat  out  all  the  alloy  if  its  particles  are  too  much  surrounded  with  the 
particles  of  gold.     From  the  old  rule — one-fourth  gold,  three-fourths 

44 


690  MECHANICS. 

alloy — came  the  name  given  to  this  process,  quartaiion;  it  is  also  known 
as  the  nitric  acid  process.  It  is  well  adapted  to  the  purification  of  gold 
upon  a  large  scale,  and  is  the  process  used  in  the  U".  S.  Mint.  But  it 
does  not  remove  the  platina  so  generally  found  in  dentists'  scrap  ;  and 
is  not  so  well  adapted  for  gold  of  eighteen  carat  fineness  and  upward 
as  the  next  process. 

The  nitro-rauriatic  or  aqua-regia  process  dissolves  all  the  metals  of 
the  alloy,  but  immediately  precipitates  the  silver.  The  gold  is  subse- 
quently precipitated  in  a  state  of  purity,  thoroughly  washed,  dried,  and 
melted  down  with  borax.  The  process  is,  briefly,  as  follows :  Melt  the 
scrap  to  be  refined;  roll  into  a  thin  strip  and  curl  it  up  into  what  is 
technically  termed  a  cornet;  place  in  a  porcelain  vessel  and  pour  on 
the  aqua-regia,  three  or  four  ounces  to  the  ounce  of  alloy,  which  must 
be  mixed  at  the  moment  of  using,  in  the  proportion  of  one  part  of  pure 
.  nitric  acid  to  two,  two  and  a  half,  or  three  parts  of  hydrochloric  acid ; 
quicken  the  solution  by  heat  from  a  spirit-lamp,  setting  the  vessel  where 
the  nitrous  fumes  can  escape  from  the  room ;  decant  or  filter  the  so- 
lution so  as  to  separate  the  precipitated  silver;  evaporate  the  clear 
solution  over  a  spirit-lamp,  nearly  to  dryness,  add  hydrochloric  acid 
and  evaporate  a  second  time,  so  as  to  get  rid  of  all  nitric  acid. 

The  concentrated  orange-colored  solution  is  the  chloride  of  gold 
together  with  the  chloride  of  platina  and  other  metals,  from  which  it 
must  be  separated  by  precipitation.  Dilute  largely  with  water,  and 
add,  little  by  little,  a  solution  of  the  proto-sulphate  of  iron  (green 
vitriol),  until  the  dark  olive-brown  precipitate,  which  instantly 
appears,  ceases  to  form.  Pour  on  this  precipitate  some  sulphuric 
acid,  to  remove  all  trace  of  iron,  and  then  wash  several  times  with  hot 
water,  dry  it,  and  melt  with  borax  in  a  crucible. 

If  the  presence  of  much  platina  is  suspected,  the  solution  should  be 
treated  with  muriate  of  ammonia  (sal  ammoniac)  after  the  gold  has 
been  removed.  This  will  precipitate  the  platina,  w^hich  should  be 
washed,  dried  and  sold,  inasmuch  as  the  dentist  has  no  heat  sufficiently 
intense  to  melt  it.  If  the  alloy  to  be  refined  consists  simply  of  gold 
and  platina,  the  aqua-regia  solution,  after  being  made  neutral  by  twice 
evaporating  nearly  to  dryness,  should  be  diluted  with  water  and  the 
platina  precipitated  by  muriate  of  ammonia ;  then  decant  the  gold 
solution  from  the  platina  and  precipitate  the  gold  by  the  proto-sulphate 
of  iron. 

A  third  method  of  refining  is  the  sulphuric  acid  process,  which  it  is 
unnecessary  to  describe  further  than  to  say  that  it  resembles  the  quar- 
taiion process.  Gold  is  melted  with  five  to  seven  times  as  much  silver, 
granulated  and  then  boiled  three  or  four  hours  in  a  platina  or  iron 
retort  with  sulphuric  acid. 


EEFINING  AND   ALLOYING   GOLD.  691 

By  any  of  these  three  processes,  but  most  conveniently  by  the 
second,  dental  scrap  may  be  refined  to  a  purity  sufficient  for  every 
practical  purpose.  The  assayer  resorts  to  other  methods  to  obtain  the 
absolute  purity  required  in  analyses. 

Gold  still  containing  traces  of  silver  may  be  treated  with  sulphuret 
of  antimony.  This  is  done  with  a  strong  heat  in  a  covered  crucible, 
and  after  the  gold  has  been  kept  in  a  state  of  fusion  for  some  thirty  or 
forty  minutes  it  should  be  poured  out  into  an  ingot-mould,  and  sepa- 
rated from  the  antimony,  which  will  lie  at  the  top.  It  may  be  neces- 
sary to  melt  it  in  this  way  two  or  three  times,  adding,  each  time,  a  less 
quantity  of  antimony  ;  at  the  last  melting,  a  current  of  air,  from  a  pair 
of  bellows,  should  be  thrown  upon  the  surface  of  the  fused  metal,  to 
evaporate  the  antimony,  and  after  the  vapor  ceases  to  escape,  a  little 
refined  nitre  and  borax  should  be  thrown  into  the  crucible.  It  should 
then,  in  a  few  minutes,  be  poured  into  the  ingot  mould  ;  should  it  crack 
in  hammering  or  rolling,  it  must  be  again  melted,  and  a  little  more 
nitre  and  borax  thrown  on  it. 

Still  another  process  for  refining  gold  is  occasionally  used,  called 
cementation.  It  consists  in  first  rolling  the  gold  out  into  exceedingly 
thin  plates,  then  placing  it  in  a  crucible  with  a  mixture  of  four  parts 
of  brickdust,  one  of  calcined  sulphate  of  iron,  and  one  of  chloride  of 
soda.  A  bed  of  this  mixture  or  cementing  powder  is  first  placed  in 
the  bottom  of  the  crucible;  the  gold  is  then  put  in  and  covered  with 
it.  The  crucible  is  covered  with  another  crucible;  the  joints  well  luted 
with  clay,  and  gradually  raised  to  a  red  heat,  at  which  temperature  it 
should  be  .kept  from  twenty  to  twenty-four  hours.  The  crucible  is 
then  removed  from  the  fire,  the  top  broken  of,  and  after  it  has  cooled, 
the  gold  may  be  separated"  from  the  cement  and  washed,  or,  what  is 
still  better,  boiled  in  hot  water. 

The  form  of  furnace  for  melting  gold  depends  much  upon  the  kind 
of  fuel.  Charcoal,  coke  and  anthracite  are  the  three  kinds  used; 
bituminous  coal  is  inadmissible  until  converted  into  coke.  The  stove 
factories  now  furnish  so  many  convenient  forms  for  the  use  of  any  of 
these  fuels  that  we  shall  not  occupy  time  or  space  in  their  detailed 
description.  A  pipe  six  feet  high  will  give  to  the  ordinary  "preserving 
furnace"  a  draft  sufficient  to  melt  gold  with  charcoal ;  coke  gives  a 
very  intense  heat,  but  needs  a  stronger  draft ;  anthracite  requires  a 
powerful  draft,  but  gives  a  more  steady  heat,  needs  less  frequent 
renewal,  and  hence  is  better  for  long-continued  heats. 

As  regards  the  shape  and  size  of  the  stove,  the  following  points  should 
be  attended  to:  convenience  of  access  to  the  crucible;  sufficient  depth 
and  width  to  surround  the  crucible  with  a  good  body  of  fuel,  without 
unnecessary  waste  of  material. 


692  MECHANICS. 

Fletcher's  small  and  convenient  blast  crucible  furnaces,  for  melting 
gold  by  the  use  of  gas  and  refined  petroleum,  are  very  serviceable  in 
laboratory  work. 

The  Ceylonese  goldsmiths  use  a  blast  furnace  of  very  rude  and  simple 
construction.  It  consists  of  a  small,  low,  earthen  pot,  filled  with  chaff 
or  sawdust,  on  which  a  little  charcoal  fire  is  made,  which  is  excited 
with  a  small  bamboo  blowpipe,  about  six  inches  long,  the  blast  being 
directed  through  a  short,  earthen  pipe  or  nozzle,  the  end  of  which  is 
placed  at  the  bottom  of  the  fire.  By  this  simple  contrivance,  a  most 
intense  heat  may  be  obtained,  greater,  it  is  said,  than  is  required  for 
melting  gold  or  silver. 

For  separating  iron,  copper,  tin,  lead  or  zinc  from  gold,  the  following 
simple  method  may  be  adopted  :  After  passing  a  magnet  a  number  of 
times  through  the  filings  or  fragments,  to  remove  all  traces  of  iron  or 
steel,  put  the  gold  in  a  clean  crucible,  covered  with  another  crucible, 
having  a  small  opening  or  hole  through  the  top ;  lute  the  two  together 
with  clay;  place  them  in  a  bed  of  charcoal  in  the  furnace ;  ignite  the 
coal  gradually ;  afterward  increase  the  combustion  by  means  of  a  cur- 
rent of  air  from  a  pair  of  bellows,  or  by  turning  on  the  draft ;  after  the 
gold  has  melted,  throw  in,  at  intervals  of  about  ten  minutes,  several 
small  lumps  of  nitrate  of  potash  (saltpetre)  and  sub-borate  of  soda 
(borax),  and  keep  it  in  a  fused  state  for  thirty  or  forty  minutes ;  then 
remove  the  crucible,  and  plunge  in  water  to  cool  it ;  break  it  and  sepa- 
rate the  lump  of  gold  from  the  dross;  then  put  into  another  crucible; 
melt  with  a  little  borax,  and  pour  into  an  ingot  mould,  of  the  proper 
size,  previously  v/armed  and  oiled.  Bichloride  of  mercury  (corrosive 
sublimate)  is  sometimes  used  instead  of  or  after  nitre,  for  the  purpose 
of  dissipating  the  base  metals,  and  often  with  more  certain  and  better 
results,  especially  where  the  presence  of  any  tin  is  suspected.  If  the 
gold  cracks  on  being  hammered  or  rolled,  it  should  be  melted  again, 
and  more  nitre  and  borax  thrown  into  it ;  the  inside  of  the  crucible 
should  also  be  well  rubbed  with  borax,  before  the  metal  is  put  in.  It 
is  sometimes  necessary  to  repeat  this  process  several  times,  and  if  the 
gold  still  continues  brittle,  a  little  muriate  of  ammonia  (sal  ammoniac) 
may  be  thrown  into  the  crucible  when  the  gold  is  in  a  fused  state;  after 
the  vapor  ceases  to  escape,  the  metal  should  be  poured  into  an  ingot 
mould,  warmed  and  oiled  as  before  directed.  This  last  method  of  treat- 
ment will  make  the  gold  tough,  and  prevent  it  from  cracking  under  the 
hammer,  or  while  being  rolled,  provided  it  is,  from  time  to  time,  prop- 
erly annealed  during  the  process. 

By  this  method  of  refining  gold,  known  as  the  dry  process,  or  "  re- 
fining by  fire,"  sufficiently  accurate  results  will  be  obtained  for  many 
of  the  practical  purposes  of  mechanical  dentistry;  since  the  variation  of 


REFINING   AND   ALLOYING   GOLD.  693 

an  eighth  or  a  quarter  of  a  carat  in  the  fineness  of  gold  plate  is  not  often 
a  matter  of  much  consequence.  Comparing  the  two  classes  of  refining 
processes — the  humid,  by  acids,  and  the  dry,  by  fire — the  first  is  the 
more  accurate,  and  the  only  way  to  remove  platina  or  silver ;  but  it  is 
the  most  troublesome,  and  requires  a  familiarity  with  chemical  details, 
which,  unfortunately,  many  dentists  are  totally  ignorant  of.  The 
second  may  remove  the  lead,  tin,  zinc,  antimony  and  bismuth,  if  in 
small  quantity;  and  if  continued  for  a  sufficient  length  of  time,  with 
a  free  use  of  nitre,  may  remove  a  large  proportion  of  copper.  It  can 
scarcely  be  depended  upon,  if  the  object  is  to  make  an  ingot  of  pure 
gold,  but  will  answer  admirably  if  the  purpose  is  merely  to  lessen  the 
alloy  or  remove  certain  impurities. 

As  the  dry  process  is  one  that  the  dentist  will  often  have  occasion 
to  resort  to,  we  shall  give  (from  the  seventh  volume  of  the  American 
Journal  of  Dental  Science)  the  following  description  of  the  very  excel- 
lent method  pursued  by  Dr.  Elliot,  of  Montreal : — 

"The  following  implements  are  necessary  for  this  purpose:  a  small 
draught  furnace;  a  quantity  of  fine  hard-wood  coal;  a  clean  crucible, 
with  a  sheet-iron  cover  (a  lump  of  charcoal  is  better) ;  a  light  pair  of 
crucible  tongs;  an  ingot  mould,  made  of  soapstone;  a  little  nitrate  of 
potash,  carbonate  of  potash,  borax  and  oil.  The  fireplace  of  the  fur- 
nace should  be  about  ten  inches  in  diameter,  and  eight  or  ten  deep ; 
this  should  be  connected  by  means  of  a  pipe  with  the  chimney,  so  that 
a  powerful  draught  may  be  made  to  pass  through  the  coal.  A  blast 
furnace  is  objectionable,  for  the  reason  that  the  bellows  burns  out  the 
coal  immediately  under  the  crucible,  and  it  is,  therefore,  constantly 
dropping  down,  which  is  not  the  case  with  the  draught  furnace ;  besides, 
the  draught  furnace  produces  a  more  even  fire,  a  quality  equally  in- 
dispensable. 

"  In  preparing  for  a  heat,  the  furnace  should  be  filled  about  half  full 
of  coal,  and  after  it  is  well  ignited,  it  should  be  consolidated  as  much 
as  practicable  without  choking  the  draught.  The  crucible  containing 
the  metal  and  a  little  borax  may  then  be  set  on,  and  more  coal  placed 
around  and  over  it,  the  door  of  the  furnace  closed,  and  the  damper 
opened.  It  should  remain  in  this  way  until  the  gold  is  perfectly  fused. 
The  coal  may  then  be  removed  from  over  the  crucible,  and  a  bit  of 
nitrate  of  potash  dropped  in,  in  quantity  equal  to  the  size  of  a  pea  to 
every  ounce  of  gold,  and  the  crucible  immediately  covered  with  a  plate 
of  iron.  More  coal  may  then  be  placed  over  and  around  the  crucible, 
and  the  gold  kept  in  a  fused  state  at  a  high  temperature,  until  the 
scoria  ceases  to  pass  off,  which  it  will  do  in  the  course  of  five  or  six 
minutes.  The  ingot  mould,  having  been  previously  warmed,  should  be 
placed  in  a  convenient  position  for  pouring,  and  filled  about  half  full 


694  MECHANICS. 

of  lamp  oil.  The  cover  should  now  be  thrown  off  quickly,  the  crucible 
seized  with  the  tongs,  and  at  the  same  instant  another  small  bit  of 
nitrate  of  potash  should  be  thrown  into  it,  and  the  gold  rapidly,  but 
carefully,  poured  into  the  mould. 

"  The  ingot  always  cools  first  at  the  edges,  and  shrinks  away  from 
the  middle.  On  that  account,  the  mould  should  be  a  little  concave 
on  the  sides,  so  that  the  shrinking  will  not  reduce  the  ingot  thinner  in 
the  centre  than  at  the  edges. 

"Moulds  of  the  best  form  will  sometimes  produce  ingots  of  irregular 
thickness.  Such  ingots  should  be  brought  to  a  uniform  thickness 
under  the  hammer,  using  the  common  callipers  as  a  gauge.  If  this  be 
neglected,  the  plate  will  be  found  imperfect  at  those  points  where  the 
ingot  was  thinnest.  The  plate  should  be  annealed  occasionally  during 
the  process  of  hammering  and  rolling,  and  should  be  reduced  about 
.  one  number  in  thickness  each  time  it  passes  between  the  rolls.  If  any 
lead,  tin  or  zinc  be  mixed  with  the  gold,  the  nitrate  of  potash  must  be 
used  in  much  larger  quantities,  and,  in  that  case,  it  is  better  to  let  the 
button  cool  in  the  bottom  of  the  crucible.  Then  break  the  crucible, 
and  melt  it  in  a  clean  one  for  pouring,  using  borax  and  nitrate  of 
potash  in  very  small  quantities  for  the  last  melting. 

"  In  case  the  subject  of  assay  be  in  the  form  of  filings  or  dust,  a 
magnet  should  be  passed  through  it,  so  as  to  remove  every  particle  of 
iron,  and  then,  instead  of  melting  it  with  borax,  it  should  be  melted 
first  wdth  carbonate  of  potash,  and  afterward  with  nitrate  of  potash,  in 
quantities  proportioned  to  the  necessities  of  the  case,  as  before  directed. 
Carbonate  of  potash  is  the  only  flux  that  will  bring  all  the  small  par- 
ticles of  metal  into  one  mass.  Without  it,  a  great  portion  of  the  gold 
will  be  found  among  the  scoriae,  adhering  to  the  sides  of  the  crucible, 
in  the  form  of  small  globules.  This  process  of  refining  answers 
equally  as  well  for  silver  as  gold." 

ALLOTI^'G    GOLD. 

Gold,  when  in  an  unalloyed  or  pure  state,  as  before  stated,  is  too 
soft  to  be  used  as  a  support  for  artificial  teeth ;  consequently,  it  has 
been  found  necessary  to  combine  with  it  some  other  metal,  in  order  to 
harden  it.  Silver  and  copper  are  the  alloys  most  frequently  employed. 
Many  dentists  prefer  the  former,  erroneously  supposing  that  it  does  not 
increase  the  liability  of  gold  to  tarnish  as  much  as  the  latter.  But 
this  opinion  is  sustained  neither  by  facts  nor  experience.  Gold,  when 
alloyed  with  copper,  unless  reduced  altogether  too  much  for  dental 
purposes,  will  resist  the  action  of  acids  as  eflTectually  as  when  alloyed 
with  silver,  and  the  former  renders  it  much  harder  than  the  latter. 
Besides,  it  renders  the  gold  susceptible  of  a  higher  and  more  beautiful 


EEFINING   AND   ALLOYING   GOLD.  695 

finish.  If,  therefore,  but  one  of  these  metals  is  used,  copper  may  be 
regarded  as  preferable  to  silver. 

The  gold  employed  in  mechanical  dentistry  by  most  practitioners  is 
altogether  too  impure  for  the  purpose,  it  being  not  more  than  eighteen 
carats  fine,  and  sometimes  it  is  reduced  even  to  fourteen.  When  not 
above  these  standards  of  fineness,  it  is  discolored  by  the  buccal  secre- 
tions, imparts  a  disagreeable  taste  to  the  mouth,  and  becomes  brittle 
after  it  has  been  worn  for  a  few  years.  The  plate  which  is  to  serve  as 
a  basis  for  artificial  teeth  should  never  be  reduced  below  twenty  carats  ; 
and  as  that  for  the  upper  jaw  does  not  require  to  be  more  than  one-third 
or  one-half  as  thick  as  that  of  the  lower,  the  gold  for  the  latter  may 
be  a  little  finer  than  that  employed  for  the  former,  as  it  is  necessary 
that  it  should  be  more  malleable.  The  following  standards  of  fine- 
ness may  be  regarded  as  the  best  that  can  be  adopted  for  gold  used 
in  connection  with  artificial  teeth :  plate  for  the  upper  jaw,  twenty 
carats  ;  for  the  lower,  twenty-one ;  and  for  clasps  and  wire  for  spiral 
springs,  eighteen. 

In  reducing  perfectly  pure  or  twenty-four  carat  gold  to  these  stand- 
ards, first  make  an  alloy  of  copper  and  silver,  which  may  be  either  in 
the  proportion  of  copper  4,  silver  1,  or  copper  9,  silver  1,  according  to 
the  qualities  required  in  the  plate.  The  effects  of  the  two  metals  are 
in  strong  contrast — copper  giving  hardness  and  elasticity,  and  deep- 
ening the  color  into  a  red  ;  silver  preserving  the  softness,  and  giving  a 
greenish-white  shade  to  the  original  yellow  of  the  pure  gold.  Of  these 
alloys  take — to  twenty-one  grains  of  pure  gold,  three  grains ;  to  twenty 
grains  of  pure  gold,  four  grains  ;  and  to  eighteen  grains  of  pure  gold, 
six  grains  ;  to  make,  respectively,  twenty-one,  twenty  and  eighteen 
carat  gold.  In  the  latter  case,  the  alloy  should  be  used  containing 
most  silver,  as  so  large  a  percentage  of  copper  makes  the  gold  too  hard 
and  elastic,  and  gives  it  rather  too  red  a  color. 

The  gold  should  be  first  melted  in  a  clean  crucible,  and  as  soon  as 
it  has  become  thoroughly  fused,  the  silver  and  copper  alloy  may  be 
thrown  in,  with  two  or  three  small  lumps  of  borax.  After  keeping 
the  whole  in  a  melted  state  for  some  five  or  ten  minutes,  it  should  be 
quickly  poured  into  an  ingot  mould  of  the  proper  size,  previously 
warmed  and  oiled.  If  the  gold  cracks  during  the  process  of  hammer- 
ing or  rolling,  it  must  be  melted  again  and  a  few  small  pieces  of  borax 
with  a  little  muriate  of  ammonia,  thrown  in,  and  in  five  or  ten  minutes 
recast  into  an  ingot. 

"When  scraps  and  filings  are  to  be  converted  into  plate,  they  should 
first  be  refined,  afterward  properly  alloyed.  This  may  also  be  necessary 
with  all  gold  the  quality  or  fineness  of  which  is  not  known ;  but  with 
national  coins  having  a  known  fixed  standard  this  will  not  be  necessary. 


696 


MECHANICS. 


When  they  are  above  these  standards  of  fineness,  the  amount  of  alloy 
necessary  to  reduce  them  to  the  required  fineness  may  be  readily  found 
•  by  calculation.  It  is  often  unnecessary  to  change  the  fineness  of  either 
American  (21.6  carat)  or  English  (22  carat)  coin  ;  especially  when  the 
depth  of  the  plate  in  upper  cases,  or  the  prominence  of  the  ridge  in 
lower,  gives  additional  stiffness  to  the  plate. 

There  are  two  principles  upon  which  plates  are  alloyed.  The  first, 
and  common  one,  is  to  add  as  much  alloy  as  the  gold  will  stand  ;  the 
second  is  to  add  the  least  possible  quantity.  The  first  results  in 
eighteen  carat  gold,  and  uses  mainly  silver,  lest  the  six  grains  of  alloy 
should  make  it  too  brittle.  The  last  results  in  twenty  or  twenty-two 
carat  gold,  and  uses  chiefly,  or  exclusively,  copper;  since  the  least 
quantity  of  this  gives  the  greatest  stiffness. 

The  simple  rule  is  to  have  the  purest  plate  which  the  form  of  the 
mouth  will  permit.  For  shallow  mouths,  requiring  increased  stiffness, 
a  twenty-carat  plate  may  be  used  ;  but  better  practice  still  is  to  increase 
the  rigidity  by  greater  thickness,  or  sometimes  by  doubling  some  part 
of  the  plate. 

In  connection  with  the  alloying  of  gold,  it  is  proper  to  make  some 
remarks  upon  the  terms  in  which  the  fineness  of  alloys  is  expressed, 
and  the  means  of  ascertaining  it. 

Pure  gold  being  taken  as  the  starting  point,  it  may  be  expressed 
by  unity  (1),  or  by  24,  or  by  1000.  In  the  first  case,  fineness  is 
given  in  fractions.  In  the  second  case,  by  parts,  called  carats, 
which  for  convenience,  may  be  considered  as  equivalent  to  a  grain  ; 
thus  representing  pure  gold  by  24  grains,  or  1  dwt.  In  the 
third  case,  value  is  expressed  in  decimals,  and  is  the  most  con- 
venient system,  although  the  second  is  the  most  customary  with 
jewelers  and  dentists. 

The  following  table,  prepared  by  Prof.  Austen,  will  show  the  rela- 
tive value  of  these  three  systems  in  a  few  of  the  most  usual  forms  of 
gold  alloy : — 


Fractions. 

Carats. 

Decimals. 

Pare  Gold 

1. 

24. 

1000. 

English  Coin 

w 

22. 

916.6 

American  Coin 

1% 

21.6 

900. 

Dentists'  Gold,  best 

t 

20. 

833.3 

"            "       good    .... 

1 

19.2 

800.    , 

Jewelers'  Gold,  best 

f 

18. 

750. 

"            "     good   .... 

5 
T 

15. 

625. 

'*             "     common  . 

1 
2 

12. 

500. 

Commonest  Solder       .... 

1 
3" 

8. 

833.3 

REFINING    AND   ALLOYING   GOLD. 


697 


The  table  gives  the  amount  of  pure  gold ;  subtracting  which  from 
the  number  at  the  head  of  each  column  will  give  the  amount  of  alloy. 
For  example  :  best  jewelers'  gold  contains  eighteen  carats  of  pure  gold 
and  six  carats  of  alloy  ;  or  three-fourths  pure  gold  and  one-fourth  alloy ; 
or  750  parts  pure  gold  and  250  parts  alloy. 

To  know  how  much  alloy  is  required  to  reduce  gold  from  one  fine- 
ness to  another,  Prof.  Austen  gives  the  following  rule :  Divide  the  lower 
earat  (c)  by  the  difference  between  the  lower  carat  (c)  a7id  the  higher  (C)  ; 
divide  the  weight  (W)  of  the  gold  by  this  quotient  (c-H  (C — c)  ),  and  it 
will  give  the  amount  of  alloy  (A)  to  be  added.  He  also  gives  the  fol- 
lowing table  of  DIVISORS,  which  will  be  found  convenient,  as  saving 
the  necessity  of  much  calculation  : — 


Carats. 

22. 

21. 

20. 

19. 

18. 

16. 

14. 

12. 

24. 

11. 

7. 

5. 

3.8 

3. 

2. 

1.4 

1. 

22. 

21. 

10. 

6.3 

4.5 

2.6 

1.7 

1.2 

21.6 

35. 

12.5 

7.3 

5. 

2.8 

1.8 

1.3 

20. 

19. 

9. 

4. 

2.3 

1.5 

18. 

8. 

3.5 

2. 

The  first  vertical  column  represents  the  fineness  before  alloying  ;  the 
first  horizontal  column  the  fineness  after  alloying.  Example  :  To  reduce 
a  double  eagle  (weighing  516  grains,  and  21.6  carats  fine)  to  20,  18, 
and  12  carat  plate,  divide  the  weight  12?,  5  and  H  ;  this  gives  the 
amounts  of  alloy  to  be  added — for  the  first,  41.3  grains;  for  the 
second,  103.2  grains;  and  for  the  third,  387  grains. 

When  it  is  required  to  know  the  fineness  of  the  plate  or  solder  made 
from  known  quantities  of  gold  and  alloy,  multiply  the  weight  (W)  of 
gold,  before  alloying,  by  its  carat  valuation  (C) ;  divide  this  product  (CW) 
by  the  weight  of  the  gold  after  alloying  (W-fA)  ;  the  quotient  will  be 
the  carat  value  (c)  of  the  alloyed  gold. 

This  and  the  preceding  rules  may  be  also  expressed  by  algebraic 
formulae : — 

c                                                  CW 
(1)         A=W-i- .  (2)         c  = . 


C— c 


W+A 


The  fineness  of  any  mixture  of  alloys  of  known  value  may  be  found 
by  a  simple  arithmetical  rule.  Multiply  each  Aveight  by  its  carat  (pure 
gold  being  24),  divide  the  sum  of  the  products  by  the  sum  of  the  weights, 
and  the  quotient  will  be  the  carat  value  of  the  mass. 

The  following  formulas  may  be  employed  for  manufacturing  gold 
plate  from  pure  gold  for  dental  purposes :  Nos.  1,  2  and  3  for  the  base, 
and  No.  4  for  clasps : — 


698 


MECHANICS. 


No.  1. 

Gold  Plate  18  carats  fine. 

18  dwts.       .         .         .  pure  gold, 

4  dwts.  .         .         .        pure  copper, 

2  dwts.       .         .         .  pure  silver. 

No.  3. 
Gold  Plate  21  carats  fine. 
21  dwts.       .         .         .  pure  gold, 

pure  copper, 


No.  2. 
Gold  Plate  20  carats  fine. 
20  dwts.       .         .         .  pure  gold, 

pure  copper. 


2  dwts.  . 


2  dwts. 


pure  silver. 


2  dwts. 
1  dwt. 


pure  silver, 


No.  4. 

Gold  Plate  20  carats  fine. 
20  dwts.       .         .         .  pure  gold, 
2  dwts.  .  .       pure  copper, 


1  dwt. 
1  dwt. 


pure  silver, 
platinum. 


The  following  formulas  may  be  employed  for  manufacturing  gold 
plate  from  coin  gold :  No.  1  for  the  base  and  No.  2  for  clasps : — 


No.  1. 

Gold  Plate  18  carats  fine. 

20  dwts.       .         .         .  gold  coin. 

2  dwts.  .         .         .        pure  copper. 

2  dwts,       .         .         .  pure  silver. 


No.  2. 
Gold  Plate  20  carats  fine. 
20  dwts.       .         .         .  coin  gold, 

8  grs.     .         .         .        pure  copper, 
10  grs.  .         .         ,  pure  silver, 

20  grs.     .         .         .        platinum. 


CHAPTER  VII. 


INGOT   MOULDS,    ROLLING   MILLS,   SOLDER. 

THE  gold,  after  being  refined  or  alloyed,  should  then  be  remelted 
in  a  clean  crucible,  well  rubbed  on  the  inside  with  borax,  and 
poured  into  an  ingot  mould  (Figs.  507,  508)  of  proper  length,  width 
and  thickness. 


Fia.  507. 


Fig.  508. 


INGOT   MOULDS,    ROLLING   MILLS,  SOLDER.  699 

Ingot  moulds  may  be  of  iron,  soapstone,  or  charcoal.  The  first  is 
perhaps  most  convenient.  The  second  gives,  with  the  same  gold,  a 
tougher  ingot ;  whilst  with  the  last  the  greatest  toughness  of  metal  is 
obtained,  so  far  as  the  nature  of  the  ingot  mould  can  modify  it.  Pig 
iron,  from  the  same  furnace,  run  into  iron  moulds,  may  be  white  and 
brittle;  or  into  sand  moulds,  gray  and  less  brittle;  or  into  charcoal, 
dark  gray  and  soft.  Some  such  modification  of  the  molecular  arrange- 
ment of  gold,  due  to  its  manner  of  cooling,  is  probably  the  correct 
explanation  of  the  fact  that  a  charcoal  mould  yields,  other  things 
being  equal,  a  tougher  ingot  than  iron. 

An  apparatus  is  now  in  use,  which  combines  the  crucible  and  ingot 
mould,  in  which  a  crucible,  of  moulded  carbon,  communicates  with 
an  ingot  mould,  both  held  in  position  by  a  clamp  underneath,  and 
swiveling  on  a  cast-iron  stand.  The  metal  to  be  melted  is  placed  in 
the  crucible,  and  the  flame  of  a  blowpipe  is  directed  on  it  until  it  is 
perfectly  fused.  The  waste  heat  serves  to  make  the  ingot  mould  hot, 
and  the  whole  is  tilted  over  by  means  of  an  upright  handle  at  the 
back  of  the  mould.  A  sound  ingot  may  be  obtained  at  any  time  in 
about  two  minutes. 

The  charcoal  ingot  mould  is  easily  made.  Select  a  firm-grained 
piece ;  saw  in  half  and  make  smooth  by  rubbing  the  surfaces  together. 
Then  make  the  matrix  in  one  of  three  ways :  either  cut  the  shape 
required  out  of  one-half,  with  the  proper  gate ;  or  bend  a  heavy  wire 
into  shape  of  the  ingot  and  gate  and  bind  it  between  the  surfaces ;  or 
saw  off  a  charcoal  slab,  and  after  cutting  out  the  shape  of  the  ingot 
and  gate,  bind  it  between  the  surfaces.  Those  who  have  once  used  a 
charcoal  ingot,  will  seldom  use  any  other. 

After  it  has  become  sufficiently  cool,  it  may  be  placed  on  an  anvil, 
and  its  thickness  reduced  to  about  an  eighth  of  an  inch,  with  a  hammer 
weighing  from  one  to  one  and  a  half  pounds.  It  should  then  be  well 
annealed  by  being  placed  in  the  furnace,  lightly  covered  with  small 
pieces  of  charcoal,  and  heated  until  it  assumes  a  uniform  cherry-red 
color;  or  it  may  be  annealed  with  the  blowpipe.  It  may  be  necessary, 
during  the  operation  of  hammering,  to  subject  it  once  or  twice  to  this 
process,  to  prevent  the  gold  from  cracking.  If,  notwithstanding  this 
precaution,  it  should  crack,  it  must  be  again  melted,  and  refined 
with  muriate  of  ammonia.  Sudden  cooling  does  not  make  it  brittle. 
On  the  contrary,  some  jewelers  maintain,  that  if  plunged  in  alcohol 
and  water,  it  is  softer  than  when  slowly  cooled.  A  little  sulphuric 
acid  in  the  water  will  give  a  bright  surface  to  the  plate,  by  cleans- 
ing off"  the  oxide  of  copper;  but  this  acid  pickle  is  only  necessary 
for  removal  of  the  metal  of  the  dies  used  in  swaffina;,  or  of  the 


700 


MECHANICS. 


borax  used  in  soldering;  in  all  other  cases  we  prefer  to  have  the 
oxide  coating. 

After  the  gold  has  been  reduced  to  the  thickness  just  mentioned, 
and  well  annealed,  it  may  be  placed  between  the  rolls  of  the  mill, 
previously  so  adjusted  as  to  be  the  same  distance  apart  at  both  ends, 
and  not  so  near  to  each  other  as  to  require  a  great  effort  to  force  it 
between  them.  The  rollers,  however,  should  be  brought  a  little  nearer 
to  each  other  every  time  the  plate  is  passed  between  them  ;  and  during 
this  process  they  should  be  kept  well  oiled,  so  that  there  may  be  as 
little  friction  as  possible.  Many  roll  the  ingot  without  any  previous 
hammering.  In  the  process  of  rolling  care  must  be  had  to  anneal 
often,  and  to  roll  in  one  direction  until  sufficient  width  of  plate  is 
obtained ;  then,  before  cross-rolling,  be  sure  to  anneal,  else  the  plate 
will  be  very  apt  to  crack. 


Fig.  509. 


Fig.  510. 


Rolling  mills  for  gold  are  variously  constructed.  Some  are  very 
simple,  while  others  are  quite  complex,  having  a  great  deal  of  machinery 
connected  with  them.  The  rollers  also  vary  in  length,  from  three  to 
five  inches.  For  the  gold  plate  used  by  dentists,  they  need  not  be 
more  than  three  or  three  and  a  half  inches  long.  Fig.  509  represents 
a  simple  form  of  rolling  mill,  without  the  cog  gearing,  as  seen  in 
Fig.  510.  The  latter  is  a  strong  but  simple  mill,  and  is  very  well 
suited  to  the  dental  laboratory.  The  set  screws  at  the  top  are  turned 
with  a  rod,  and  must  be  both  moved  alike,  else  the  plate  will  be  thicker 
on  one  side,  and  will  curve  laterally  in  rolling. 

Fig.  511  represents  a  more  complicated  mill,  designed  for  those  who 
do  much  or  heavy  rolling.  With  such  a  mill,  all  the  heavy  rolling  of 
a  laboratory  could  be  done  w'ithout  the  aid  of  an  assistant. 

The  thickness  of  the  plate  may  be  determined  by  a  gauge  plate. 


INGOT   MOULDS,  ROLLING   MILLS,  SOLDER. 


701 


That  which  is  to  serve  as  a  basis  for  artificial  teeth  for  the  upper  jaw 
may  be  reduced  uutil  it  fits  the  gauge  at  25,  26  or  27,  according  to  the 
quality  of  the  plate  and  the  depth  or  irregularity  of  the  arch.  For  the 
lower  ja^v,  and  for  backings  and  clasps,  it  may  range  from  21  to  24. 
When  the  whole  alveolar  border  and  a  portion  of  the  roof  of  the  mouth 
is  to  be  covered,  it  may  be  a  little  thinner  than  when  applied  only  to 
a  small  surface;  also  thinner  when  the  arch  is  deep  or  irregular.  The 
purer  the  gold  is,  the  thicker  must  be  the  plate.  When  very  wide 
clasps,  too,  are  employed,  it  is  not  necessary  that  the  gold  should  be 
as  thick  as  if  required  for  narrow 
ones;  and  low  or  wide  backings  ^^' 

need  not  be  so  thick  as  long  or 
narrow  ones.  Low'er  plates,  if 
wired  ai'ound  the  edge  or  doubled 
over  the  middle  third,  may  be 
made  of  the  same  thickness  as 
an  upper  plate.  But  these  are 
matters  which  the  judgment  of 
the  dentist  alone  can  properly 
determine,  and,  consequently,  no 
rulf  s  can  be  laid  down  upon  this 
subject  from  which  it  will  not 
sometimes  be  necessary  to  devi- 
ate. 

Gauge  plates  are,  unfortu- 
nately, not  uniform.  For  many 
years  the  most  reliable  were 
those  manufactured  by  Stubbs. 
But  it  is  diflBcult  to  procure 
them.  At  the  same  time  it  is 
very  important  that  some  stand- 
ard should  be  adopted  in  the 
profession.  Under  these  cir- 
cumstances we  approve  the  sug- 
gestion of  Dr.  S.  S.  White,  who  recommends  the  gauge  plate  given  in 
Fig.  512,  which  has  been  adopted  by  the  principal  brass  manufacturers 
of  this  country. 

It  may  be  necessary  sometimes  to  make  gold  wire  for  spiral  springs 
or  other  purposes,  also  hollow-tube  wire.  A  draw  plate  (Fig.  513), 
strong  pliers  and  bench  vise  (Fig.  514)  are  the  necessary  tools  for  this 
purpose.  The  draw  plate  should  be  of  the  hardest  steel,  with  the  holes 
diminishing  very  gradually.  The  pliers  should  be  rough  at  the  end, 
for  grasping  the  wire,  which  must  be  often  annealed  during  the  process. 


702 


MECHANIC'S. 


Tube  wire  may  be  obtained 
from  the  jewelers,  by  whom 
it  is  known  as  joint  wire. 
But  it  is  seldom  over  sixteen 
carats  fine.  For  use  in  the 
mouth  it  should  be  not  less 
than  twenty  carats;  but  for 
many  purposes,  pure  gold  or 
platinum  tubing  is  better.  It 
is  easily  made  as  follows : 
Takea  small  strip  of  plate  one- 
fourth  of  an  inch  wide,  one 
or  two  inches  long ;  slightly 
taper  one  end  ;  bend  it  around 
a  mandrel  or  common  knitting 
needle,  and  pass  it  into  one  of 
Then  with  the  pliers  draw  it 
through,  and  repeat  until  the  edges  of  the  strip  meet.     Remove  the 


\    O      -?/?   "WHLE  GAUGE     .,J  ^^ 
^^j5    5'   28    2D  30   ^^^ 

the  larger  holes  of  the  draw  plate. 


Fig.  513. 


mandrel  and  solder  the  seam  with  fine  gold  or  else  pure  gold.  Lastly, 
select  a  mandrel  or  needle,  the  size  of  the  required  tube,  and  draw 
the  wire  until  it  has  the  proper  thickness.  If  the  bore  is  to  be  smaller 
than  any  needle  at  hand,  the  last  drawing  may  be  done  without  the 
mandrel. 

The  simplest  method  of  winding  wire  into  a  spiral  spring  is  to  secure 
it  between  two  blocks  of  wood,  held  between  the  jaws  of  a  small  bench 
vise,  as  shown  in  Fig.  514.  The  upper  end  of  the  wire  is  then  grasped 
by  a  hand  vise  or  sliding  tongs,  in  connection  with  a  spindle  or  steel 
wire  the  size  of  a  small  knitting  needle,  six  or  eig;ht  inches  in  length. 


INGOT   MOULDS,  ROLLING   MILLS,  SOLDER.  703 

Fig.  514. 


The  spindle,  resting  on  the  blocks  of  wood,  is  made  to  revolve,  and  by 
this  movement  the  gold  wire  is  drawn  through  the  blocks  and  wound 
firmly  and  closely  round  the  steel  rod. 

GOLD   SOLDER. 

In  making  gold  solder,  the  materials  employed  for  the  purpose,  if 
not  pure,  should  be  refined  separately.  Unless  this  is  done,  it  will  be 
difficult,  and  often  impossible,  to  ascertain  their  relative  purity,  which 
should  be  known,  to  insure  the  desired  result.  The  gold  is  placed  in 
a  clean  crucible  with  a  little  borax,  and  as  soon  as  it  has  become  per- 
fectly melted,  the  silver  and  afterward  the  copper  are  added.  When 
all  are  melted,  the  alloy  may  be  immediately  poured  into  an  ingot 
mould,  previously  warmed  and  oiled.  The  process  of  hammering  and 
rolling  the  solder  is  the  same  as  that  described  for  gold  plate.  In 
consequence  of  the  large  amount  of  alloy  in  solder,  it  is  sometimes  so 
stiff",  and  even  brittle,  as  to  be  with  great  difficulty  rolled ;  this  diffi- 
culty is  increased  by  the  fact  that  its  low  fusibility  makes  it  not  very 
easy  to  anneal  without  melting.  This  is  especially  the  case  with  solders 
in  which  zinc  or  brass  is  used. 

In  making  solder  into  the  composition  of  which  zinc  enters,  the  other 
ingredients  must  be  thoroughly  melted,  then  the  zinc  (or  brass)  intro- 
duced at  the  last  moment,  rapidly  stirred,  and  the  metal  poured.  A 
piece  of  charcoal  will  be  found  better  for  making  small  quantities  of 
solder  than  a  crucible. 

The  solder  employed  for  uniting  the  various  parts  of  a  piece  of 
dental  mechanism  should  be  sufficiently  fine  to  prevent  it  from  being 
easily  acted  on  by  the  secretions  of  the  mouth. 


704  MECHANICS. 

If  pure  gold  is  used,  the  solder  will  be  of  finer  quality  than  if  twenty- 
two  carat  gold  is  used,  but  will  not  flow  quite  so  readily.  But  twenty- 
two-carat  plate  may  be  used,  if  its  alloy  is  known,  by  making  due 
allowance  for  the  amount,  which  is  easily  calculated  by  use  of  preceding 

rules.     The  following  makes  a  solder  sixteen  carats  fine,  and  may  be 
used  for  eighteen-  or  twenty-carat  gold  plate ;  it  flows  very  freely. 

No.  1. — Pure  gold, 6  dwts. 

Fine  silver,       .         .         .         .         .         .  1     " 

Roset  copper, 2     " 

By  adding  one  or  two  grains  of  zinc,  a  solder  may  be  made  that 
will  flow  at  a  lower  temperature  than  that  made  by  recipe  No.  1.  It 
will  also  have  a  finer  gold  color ;  but  it  is  apt  to  impart  to  the  piece  a 
brassy  taste,  and  for  this  reason  the  author  rarely  uses  it.  Zinc  solders 
are  apt  not  only  to  have  a  brassy  taste,  but  also  to  become  brittle  after 
long  use. 

The  following  formulas,  taken  from  Dr.  Richardson's  work  on 
"Mechanical  Dentistry,"  furnish  solders  (No.  2)  over  fifteen  carats 
fine,  and  (No.  o)  eighteen  carats  fine. 

No.  2.  No.  3. 


Gold  coin. 

6  dwts. 

Gold  coin, 

.     30  parts. 

Silver, 

30  grs. 

Silver, 

4      " 

Copper, 

.     20    " 

Copper, 

.       1      " 

Brass, 

10    " 

Brass, 

1       " 

Other  recipes  might  be  added,  but  the  foregoing  have  been  found 
with  us  to  answer  every  purpose.  More  difficulty  arises  in  the  use  of 
solders  from  a  wrong  method  of  soldering  than  from  defect  in  the 
solders  themselves.  Almost  every  dentist  will  be  found  to  have  his 
favorite  recipe,  which  "invariably  flows  smoothly."  The  very  fact 
that  so  many  hundred  different  solders  work  so  well  goes  far  to  prove 
what  we  have  said.  Some  will  boast  of  using  a  solder  as  fine  as  the 
plate.  This  may  be  true  if,  by  "fineness,"  we  mean  simply  carat 
valuation.  But  a  solder  containing  two  grains  of  zinc  to  the  dwt.  is 
in  no  true  sense  as  fine  as  a  plate  alloyed  with  that  amount  of  coi^per; 
yet  both  are  twenty-two-carat  metal.  Rules  for  the  management  of 
solder,  plate  and  blowpipe,  in  the  act  of  soldering,  will  be  hereafter 
given. 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH.  705 


CHAPTER  VIII. 

CUPS   AND    MATERIALS    FOR   IMPRESSIONS    OF   THE    MOUTH — PLASTER 

MODELS. 

IN  the  construction  of  a  dental  substitute,  mounted  upon  a  plate  or 
base,  it  is  necessary  to  obtain  an  exact  model  of  the  parts  upon 
which  it  is  to  rest,  and  to  which  it  is  to  be  attached.  For  this  purpose 
a  perfect  impression  of  these  parts  must  be  obtained,  involving — first, 
the  choice  of  a-  suitable  impression  cup  ;  secondly,  the  selection  of  an 
impression  material. 

IMPRESSION   CUPS 

Must  be  of  such  size  and  shape  as  to  permit  their  easy  introduction 
into  the  mouth ;  also  must  they  follow,  as  nearly  as  possible,  the  outline 
of  the  surfaces  to  be  copied,  allowing  a  uniform  space  of  one-fourth 
or  one-eighth  of  an  inch  for  the  material.  These  cups  are  sometimes 
called  mouth  cups  or  wax  holders ;  but  we  think  the  name  given,  and 
now  generally  used,  is  greatly  to  be  preferred.  They  are  of  two  kinds, 
metallic  and  gutta-percha. 

Metallic  cups  formerly  were  made  of  sheet  tin  (Fig.  515),  cut  into 
shape  and  soldered,  and  were  so  imperfect 
that  it  was  very  often  necessary  to  swage  ^^^'  '^^^• 

metallic  cups  to  suit  special  cases.  The 
depots  now  supply  an  excellent  assortment 
of  well-shaped  Britannia  impression  cups, 
of  which  sixteen  will  constitute  a  full  set ; 
namely,  six  sizes  for  full  upper  cases  (Figs. 
518  and  519),  and  three  for  full  lower 
(Fig.  521) ;  three  sizes  for  partial  upper  cases  (Fig.  520),  (in  these 
the  outer  rim  rises  at  a  right  angle)  ;  and  four  for  partial  lower  (these 
cups  have  a  depression  (Fig.  522),  or  a  place  cut  out  (Figs.  523,  524) 
to  receive  the  front  teeth). 

Fig.  525  represents  Dr.  Franklin's  cup  for  full  lower  impressions ;  the 
slot  and  upper  groove  permit  secondary  pressure  of  the  wax  or  plaster, 
after  the  surplus  material  is  forced  up,  as  it  is  pressed  on  the  alveolus. 

Fig.  516  represents  the  Wardle  cup,  which  is  supplied  with  a 
movable  palate  plate,  so  adjusted  that  it  is  capable  of  forcing  the 
centre  of  the  impression  material  against  the  highest  part  of  the  arch, 
as  well  as  laterally  against  the  palatal  sides  of  the  necks  of  any 
remaining  teeth. 

45 


706 


MECHANICS. 
Fig.  516. 


Fig 


Fig.  517  represents  Fouke's  impression  cup,  by  whicli  it  is  claimed 
a  correct  impression  in  all  variety  of  cases,  both  partial  and  full,  can 
be  obtained.     It  consists  of  a  metallic  portion  with  a  canvas  lining. 

The  design  of  the  cup  suggests 
of  itself  the  manner  of  using  it ; 
which  consists  of  the  ordinary 
pressure  against  the  metallic  part 
of  the  cup,  in  connection  with  a 
proper  distribution  of  pressure 
with  the  fingers  and  compressing 
instrument.  A,  against  the  can- 
vas lining  of  the  cup,  C  C ; 
which  latter  pressure  must  be 
made  with  a  degree  of  firmness 
and  steadiness  sufficient  to  com- 
press thoroughly  all  j)arts  of  the 
mouth. 


Exceptional  cases,  which  no  form  of  j^urchased  cup  will  suit,  may 
require  a  swaged  brass,  zinc,  copper,  or  silver  cup  ;  or  a  cup  cast  out 
of  Britannia  metal,  or  other  tin  alloy.  The  process  of  swaging  will 
hereafter  be  described ;  also,  the  method  of  moulding  a  cup  from  a 
pattern  of  wax.  Most  of  these  cases,  however,  may  be  met  by  bending, 
hammering,  or  cutting  the  ordinary  Britannia  cup ;  remembering 
always  that  a  wise  economy  never  hesitates  to  sacrifice  the  cup,  to 
secure  excellence  of  the  impression  or  the  saving  of  time.     Without 


MATERIALS    FOR   IMPRESSIONS    OF   THE   MOUTH. 


707 


this  adaptation  of  the  cup  to  the  form  of  the  alveolar  ridge  and  palate, 
it  is  impossible,  in  certain  mouths,  to  get  a  good  wax  or  gutta-percha 
impression. 

Cups  similar  in  shape  to  the  Britannia,  but  not  in  so  many  varieties 
of  size  are  also  made  of  hard  rubber  and  porcelain.  The  first  cannot 
easily,  and  the  latter  cannot  at  all,  be  modified  in  shape  to  suit  special 


Fig.  Sl'^. 


Fig.  520. 


Fig.  624. 


Fig.  519. 


Fig.  521. 


Fig.  523. 


Fig.  525. 


cases.  The  porcelain  cups  are  handsome  and  clean  looking,  but  they 
are  easily  broken  ;  and  when  plaster  is  used,  it  will  sometimes  leave 
the  glazed  surface  and  cling  to  the  mouth.  "VVe,  therefore,  prefer  the 
Britannia  cup,  unless  the  case  requires  Prof.  Austen's  gutta-percha 
cup. 


708  MECHANICS. 

These  cups  were  originally  devised  to  meet  a  difficulty  incident  to 
vulcanite  partial  pieces.  Perfect  impressions  of  dovetailed  interdental 
spaces,  and  the  lingual  side  of  molars  and  bicuspids,  often  undercut, 
are  impossible  in  wax  or  gutta-percha.  Yet  Prof.  A.  regards  this  as 
essential  to  the  proper  construction  of  a  partial  vulcanite  set  of  teeth. 

They  are  thus  made :  Take  a  wax  impression  and  make  a  model ; 
in  partial  cases,  brush  over  the  teeth  of  the  model  one  or  two  layers 
of  thin  plaster,  to  fill  up  all  undercuts,  and  to  make  the  plate  fit  loosely  ; 
saturate  the  model  with  water,  and  mould  over  it  a  gutta-percha  cup. 
This  last  is  done,  not  by  using  the  gutta-percha  in  sheet,  but  by  first 
making  into  a  ball ;  then  working  it  from  the  palate  outward,  leaving 
a  thick  mass  in  the  centre.  It  should  be,  on  the  inside,  from  one- 
fourth  to  one-half  of  an  inch  thick,  so  as  to  be  stiff  and  unyielding  ;  but 
on  the  outside  not  more  than  one-eighth  or  one-sixteenth  thick,  so  as 
to  be  slightly  elastic  and  yielding.  The  whole  inside  of  the  cup  must 
be  roughened  up  with  a  scaler  or  excavator  in  such  a  way  that  the 
plaster  can  take  firm  hold.  In  most  partial  cases,  the  impression  will 
have  to  be  removed  in  sections ;  the  inside  remaining  entire,  but  the 
outside  and  the  parts  between  the  teeth  coming  away  separately.  In 
certain  cases,  it  is  necessary  to  partially  cut  through  the  cup  bef  )re 
putting  in  the  plaster,  and  usually  upon  the  thick  masses  of  gum 
which  fill  the  interdental  spaces.  A  cut  on  the  inside,  in  line  with  the 
ridge,  gives  pliancy  to  an  otherwise  rigid  cup,  and  permits  its  easy 
removal.  When  it  is  desirable  to  extend  the  cup  around  the  entire 
arch,  so  as  to  get  an  exact  plaster  impression,  not  only  of  the  gum  but 
of  all  the  remaining  teeth,  this  rim  of  gutta-percha  must  be  slit  at  two 
or  three  points,  to  give  that  pliancy  which  is  a  chief  merit  in  this  form 
of  cup.  These  cups  have  no  handle,  but  are  removed  by  inserting  a 
plugging  instrument  into  a  small  hole  previously  made  in  the  back 
part  of  the  cup,  where  it  is  thickest. 

IMPRESSION    MATERIALS 

Must  possess  the  following  properties :  (1)  Plasticity  in  sufiicient 
degree  to  copy  mucous  tissues,  avoiding  the  extremes  of  softness,  which 
permits  them  to  flow  from  the  cup,  and  of  hardness,  which  requires 
excessive  pressure.  (2)  The  property  of  hardening  within  a  short  time, 
and  under  conditions  not  incompatible  with  the  mouth.  (3)  Absence 
of  expansion  or  contraction,  except  in  very  moderate  degree.  It  may 
also  be  added  that  the  materials  should  not  be  such  as,  in  taste,  smell 
or  appearance,  are  calculated  to  disgust  a  patient. 

There  are  four  materials  answering  to  these  requirements,  and  pos- 
sessing properties  as  distinctive  as  the  sources  whence  they  are  derived. 
From  the  Animal  kingdom,  Beeswax  ;  from  the  Vegetable  kingdom, 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH.  709 

Gutta-Perciia  and  Modeling  Composition  ;  from  the  Mineral  king- 
dom, Plaster.  After  their  separate  description,  a  brief  review  of 
their  distinctive  properties  will  be  given.  No  one  of  the  four  can  be 
dispensed  with  ;  no  one  should  be  exclusively  used. 

Beeswax. — Formerly  the  only  material  used,  and  is  yet  very  useful 
for  certain  cases,  and  is  absolutely  indispensable  for  other  dental  pur- 
poses. The  best  wax  is  from  virgin  combs,  and  has  a  rich  golden  color. 
Commercial  adulterations  with  tallow,  etc.,  injure  it,  and  mixture  with 
resin  makes  it  harsh  and  difficult  to  manage.  Gutta-percha  is  some- 
times incorporated  with  it  to  give  hardness  in  warm  weather  ;  bleached 
or  white  wax  is  also  used  for  thie  same  purpose. 

A  very  valuable  addition  is  paraffine.  Pure  paraffine  is  very  plastic, 
softening  at  a  low  temperature  (100^);  but  the  folds  of  soft  paraffine 
have  no  t'endency  to  reunite,  and  consequently  the  mass  is  full  of  easily 
separated  flakes  or  layers.  It  imparts  this  property  to  wax,  if  in  too 
large  proportion  ;  but  its  moderate  use  greatly  improves  the  wax.  It 
causes  it  to  soften  at  lower  heat,  makes  it  more  plastic  when  warm,  and 
harder  when  cool. 

The  depots  furnish  wax  and  its  compounds  in  very  pure,  neat,  and 
convenient  forms ;  so  that  there  is  now  little  necessity  for  the  dentist  to 
spend  the  time  once  demanded  to  reduce  the  thick  cakes  into  service- 
able shape.  It  may  be  well,  however,  to  state  briefly  how  to  prepare 
wax  for  impressions.  Melt  and  pour  into  cakes  one-quarter  of  an  inch 
thick;  cut  into  pieces  about  two  inches  square;  and  when  nearly  cold, 
roll  on  a  wet  board,  with  a  wet  wooden  roller,  to  one-half  or  one-fourth 
this  thickness.  This  breaks  down  the  crystallization,  and  reduces  it 
to  a  form  very  convenient  for  softening  when  wanted  for  use.  It  may 
be  softened  over  a  broad  flame,  or  before  a  fire  or  stove,  or  in  warm 
water.  In  using  dry  heat,  be  careful  not  to  melt  the  surface,  or  give 
the  peculiar  whitish  appearance  that  precedes  melting.  In  using 
water,  have  a  large  quantity,  to  secure  uniformity  of  temperature,  and 
keep  it  at  120°-130°  Fahrenheit.  Below  this  it  will  not  yield  readily 
to  the  gum  ;  above  this  it  becomes  adhesive. 

Some  practice  is  necessary  in  knowing  the  proper  quantity  of  wax  to 
use  in  the  cup ;  the  usual  mistake  is  to  take  too  much.  Select  a  cup  of 
proper  shape  and  size ;  if  the  arch  is  a  deep  one,  put  some  hard  wax 
or  gutta-percha  in  the  centre,  to  force  up  the  wax  at  that  point.  This 
is  much  better  than  to  have  a  hole  in  the  cup  through  which  to  make 
pressure  with  the  finger.  Such  cups  are  worse  than  useless,  for  it  is 
impossible  to  make  secondary  pressure  without  injury  to  other  parts 
of  the  impression ;  except  in  case  of  wax  projecting  above  the  cup, 
outside  the  ridge.  Put  the  wax  in  the  cup ;  smooth  the  surface,  which 
should  be  a  little  softer  than  the  body  of  the  wax ;  then  introduce  and 


710  MECHANICS. 

press  against  the  gums  or  teeth  with  a  steady,  uniform,  and  moderately 
strong  pressure ;  also,  as  nearly  as  possible,  in  a  direction  at  right 
angles  to  the  plane  of  the  alveolar  ridge. 

The  wax  above  the  cup  is  pressed  against  the  gums  on  each  side, 
so  that  an  exact  impression  may  be  obtained  of  all  the  depressions  and 
prominences  on  the  outside  of  the  arch.  But  this  must  be  done  with 
great  care,  holding  the  cup  firmly  and  pressing  the  finger  against  the 
cheek  or  lip,  rather  than  directly  upon  the  wax.  It  is  much  better  in 
all  cases  to  have  the  sides  of  the  cup  high  enough  to  give  the  wax 
support  at  all  points.  For  this  purpose,  it  becomes  necessary  some- 
times to  swage  or  cast  a  special  cup.  Very  perfect  wax  impressions 
can  be  taken  in  such  cups.  On  the  removal  of  the  cup  and  wax 
from  the  mouth,  the  greatest  precaution  is  necessary  to  prevent 
injuring  or  altering  the  shape  of  the  impression.  Holding  the  handle 
firmly,  it  must  be  drawn  directly  downward,  in  case  there  are  front 
teeth,  in  the  direction  of  the  axes  of  these  teeth.  Impressions  of  a 
full  upper  arch  sometimes  adhere  very  tightly.  They  can  generally 
be  loosened  by  drawing  up  the  cheek  and  lip  on  one  side  or  both  sides 
alternately  ;  or  by  a  slight  cough,  which,  acting  upon  the  palate,  ad- 
mits air  behind  and  above  the  impression.  Any  violence  or  twisting 
motion  injures  the  impression ;  in  wax  or  gutta-percha  such  defects 
cannot  be  detected  until,  on  completion  of  the  plate,  maladjustment 
creates  suspicion  of  its  cause.  The  wax  must  be  kept  in  the  mouth 
long  enough  to  cool  and  harden.  A  small  piece  of  ice  in  a  napkin, 
held  against  the  under  side  of  the  cup,  will  rapidly  harden  it.  This 
simple  plan  is  preferable  to  the  use  of  double  cups,  into  which'  a  stream  of 
cold  water  is  injected.  The  latter  are  not  only  expensive  and  trouble- 
some to  use,  but  they  endanger  the  accuracy  of  the  impression.  All 
wax  impressions,  unless  for  models  on  which  other  cups  are  to  be  made, 
should  be  hardened  by  artificial  cold ;  it  greatly  helps  to  prevent 
change  of  shape  on  withdrawal.  If  the  surplus  wax,  by  contact  with 
the  lips  or  teeth,  injures  the  impression,  then,  if  it  is  a  full  case,  cut  off 
the  surplus,  dip  into  warm  water,  and  introduce  the  same  impression  a 
second  time;  but  if  it  is  a  partial  case,  it  must  be  taken  anew,  for  the 
teeth  cannot,  with  any  accuracy,  enter  their  wax  impressions. 

Gutta-Percha. — This  very  valuable  material  will  be  found  useful  in 
taking  impressions  of  the  lower  jaw  and  in  some  partial  cases,  also  fre- 
quently in  full  upper  cases  when  the  teeth  are  set  on  a  vulcanite  base. 
The  manipulations  are  different,  accordingly  as  we  wish  to  make  the 
gutta-percha  adhere  to  the  cup,  or  wish  it  to  part  from  the  sides  of  the 
cup,  as  it  shrinks  on  cooling.  In  the  first  case,  soften  in  water  heated 
tQ  180°-200°  Fahrenheit;  dry  off  the  water ;  hold  for  a  few  moments 
over  a  flame,  and  press  into  a  warm  cup ;  keep  the  fingers  wet,  to  pre- 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH.  711 

vent  the  gutta-percha  from  sticking,  but  do  not  let  water  get  between 
it  and  the  cup.  In  the  second  case  keep  the  surface  of  the  gum  wet, 
and  introduce  it  into  a  cold  and  wet  cup.  When  the  cup  is  filled,  place 
again  in  water  at  180° ;  then  press  it  somewhat  into  shape,  and  intro- 
duce into  the  mouth.  Pressure  must  be  more  gentle  than  for  wax ;  it 
must  be  kept  longer  in  the  mouth,  and  ice  should  be  used  to  cool  it. 
Be  very  careful,  in  partial  cases  where  there  is  much  undercut  or  a 
dovetail  space  between  teeth,  not  to  make  the  gutta-percha  too  hard, 
else  it  will  be  almost  impossible  to  get  it  out  of  the  mouth. 

Gutta-percha  copies  surfaces  with  all  the  accuracy  of  plaster ;  but, 
although  harder  than  Avax,  it  is  more  apt  than  plaster  to  change  its 
shape  upon  withdrawing  it  from  the  mouth.  Its  characteristic  pecu- 
liarity is  contraction  on  cooling ;  but  this  is  controlled,  when  required, 
by  the  directions  above  given  for  making  it  adhere  to  the  cup.  It  is 
less  easily  manipulated  than  wax,  and  not  so  generally  useful ;  but  its 
property  of  contraction  admirably  adapts  it  to  certain  cases  in  which 
plates,  otherwise  accurate,  fail,  because  too  large  and  loose. 

Gutta-percha  for  impressions  is  supplied  in  convenient  form  by  the 
depots.  The  native  coloy  is  dark,  and  calculated  to  repel  fastidious 
patients.  For  this  reason,  also  to  give  it  body,  it  is  incorporated  with 
about  its  own  weight  of  white  oxide  of  zinc,  magnesia  or  chalk,  and 
a  pinkish  color  given  by  vermilion.  Thus  prepared,  it  is  less  sticky 
when  softened,  and  becomes  harder,  when  cool,  than  the  crude  article. 

Modeling  Comjjosition  is  composed  of  gum  dammar,  stearine,  French 
chalk,  with  carmine  to  color  it,  and  a  perfume  to  render  it  pleasant. 
Four  varieties  are  manufactured — the  soft,  the  medium,  the  hard  and 
the  extra  soft,  differing  as  to  the  quantity  of  steainne  and  chalk  incor- 
porated with  the  gum.  Modeling  composition  is  an  excellent  material 
for  impressions,  as  it  copies  very  accurately,  and  afl^brds  a  smooth 
model.  The  best  manner  of  using  it  is  to  soften  this  material  in  boiling 
water  contained  in  a  shallow  vessel.  When  it  is  thoroughly  softened, 
and  not  too  hot  to  handle,  the  cup  for  its  reception  should  be  slightly 
warmed,  into  which  it  is  introduced  in  the  same  manner  as  wax.  After 
it  is  applied  to  the  mouth,  it  is  allowed  to  cool  somewhat,  after  being 
pressed  around  the  outside  of  the  alveolar  ridge. 

The  same  care  is  necessary  in  removing  it  from  the  mouth  as  with 
wax,  and  it  should  be  immersed  in  cold  water  at  once,  to  harden  it. 
Before  pouring  the  plaster  the  impression  should  be  dipped  in  cold 
water.  To  remove  an  impression  of  this  material  from  the  plaster 
model,  both  are  immersed  in  boiling  water,  where  they  should  remain 
until  the  compound  becomes  soft,  but  not  adhesive,  when  it  is  easily 
separated  from  the  model. 

Piaster — Gypsum,  Sulphate  of  Lime,  or  Plaster-of- Par  is — consists  of  28 


712  MECHANICS. 

parts  lime,  40  of  sulphuric  acid,  and  18  of  water;  the  first  its  mineralogi- 
cal  name,  the  second  its  chemical,  the  third  its  commercial.  A  beau- 
tiful, translucent  variety  of  gypsum  is  known  as  alabaster;  the  trans- 
parent crystalline  variety  is  called  selenite.  That,  however,  used  in 
agriculture  and  for  calcining  is  in  amorphous  masses  of  a  grayish  or 
bluish-white  color.  When  exposed  to  a  heat  between  300°  and  400° 
Fahrenheit,  most  of  the  water  of  the  gypsum  escapes.  It  is  then  known 
as  calcined  plaster,  plaster-of-Paris,  or  simply  plaster.  After  being 
properly  calcined  and  pulverized,  if  mixed  with  water  to  the  consistence 
of  thin  batter  or  cream,  it  hardens  in  a  few  minutes,  and  acquires  great 
solidity.  The  plaster  has  chemically  reunited  with  a  portion  of  the 
water,  while  another  portion  is  mechanically  held  in  the  porous  mass, 
and  may  be  driven  off  by  drying.  During  the  process  of  consolidation 
it  expands,  in  consequence  of  the  absorption  of  the  water  by  the  par- 
ticles of  plaster.  If  the  plaster  is  very  fine-grained,  this  absorption 
'  takes  place  quickly,  and  the  expansion  occurs  while  the  plaster  is  soft. 
But  coarse-grained  plaster  sets  before  the  particles  become  thoroughly 
saturated ;  hence  it  continues  to  expand,  more  or  less,  for  some  time 
after  solidification.  There  is  a  great  difference  in  the  quality  of  plaster. 
That  used  for  taking  impressions  of  the  mouth  (and,  in  fact,  for  all 
dental  purposes)  should  be  of  the  best  description,  well  calcined,  finely 
pulverized,  and  passed  through  a  sieve  of  bolting  cloth  previously  to 
being  used.  The  idea  of  taking  impressions  for  full  sets  of  teeth  with 
plaster  originated,  we  believe,  almost  simultaneously  with  Drs.  West- 
cott,  Dunning  and  Bridges,  by  whom,  and  the  profession  generally, 
it  has  been  regarded  as  adapted  almost  exclusively  to  full  impres* 
sions.  Prof.  Austen  introduced  a  method  of  using  it  in  connection 
with  gutta-percha  cups,  which  makes  it,  in  the  hands  of  a  careful 
manipulator,  universally  applicable  to  every  case  in  which  a  dental 
appliance  is  called  for.  He  would,  however,  by  no  means  recommend 
such  universal  application,  claiming  only  that  the  gutta-percha  cup 
will  give  with  plaster  a  correct  impression  of  partial  cases  of  greatest 
irregularity,  where  the  use  of  wax  or  gutta-percha  would  be  impos- 
sible. 

For  plaster  impressions  in  ordinary  full  cases,  upper  or  lower,  select 
a  Britannia  cup,  about  one- eighth  of  an  inch  larger  than  the  alveolar 
ridge,  and,  in  case  of  a  deep  upper  arch,  build  up  with  wax,  so  as  to 
^give  support  to  the  soft  plaster;  also  supply  with  wax  any  deficiency 
in  the  size  of  the  cup  at  the  back  part  or  around  the  outside  edge.  In 
exceptional  cases,  requiring  a  special  cup,  a  gutta-percha  one  will  be 
found  to  be  much  easier  made  than  a  swaged  or  cast  metallic  cup.  If 
properly  shaped,  it  will  fully  answer  the  purpose. 

The  late  Dr.  Bean's  practice  was  to  take  a  wax  impression,  make 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH.  713 

model  and  dies,  and  swage  a  plate;  then  solder  a  strip  from  ridge  to 
ridge,  to  hold  a  stick,  which  was  to  act  as  a  handle  in  removing  the 
impression.  He  then  heated  the  plate,  and  coated  the  palatine  surface 
with  shellac,  pressing  a  lump  of  raw  cotton  against  the  adhesive  resin. 
The  cotton  fibres  caused  the  plaster  to  adhere  firmly  to  the  plate,  thus 
avoiding  the  great  annoyance  when  scales  of  plaster,  so  thin  as  in  this 
kind  of  cup,  break  off.  The  process  is  troublesome,  but  the  results  very 
satisfactory. 

To  take  a  plaster  impression,  place  the  patient  in  a  common  chair, 
and  after  the  cup  is  introduced,  incline  the  head  forward,  holding  it 
in  place  with  a  gentle  but  steady  pressure  upon  the  centre  of  the  cup. 
The  plaster  should  be  very  fine-grained  and  mixed  rather  thin,  to  get 
rid  of  air  bubbles.  If  necessary,  a  little  salt  or  a  few  grains  of 
sulphate  of  potash  should  be  added,  to  quicken  slow-setting  plaster. 
The  necessity  for  salt  and  quantity  to  be  used  should  not  be  left  to 
conjecture ;  hence  the  importance  of  setting  aside  in  a  well-closed 
vessel  a  quantity  of  "  impression  plaster."  Also,  if  the  plaster  is 
"  slow,"  set  aside  a  large  bottle  of  salt  water  of  the  exact  strength 
required  to  make  that  plaster  set  properly.  There  will  in  this  way 
be  no  danger  of  the  plaster  setting  too  quickly  or  too  slowly.  If 
made  to  set  too  rapidly,  it  hurries  the  operator  and  increases  the  risk 
of  failure;  if  it  sets  too  slowly,  both  patient  and  operator  become 
wearied  before  it  is  hard  enough  to  remove.  Tepid  water  promotes 
the  setting  of  plaster.  It  should  require  about  three  minutes  to 
harden  after  it  is  introduced  into  the  mouth,  which  must  be  done 
when  it  is  stiff  enough  to  allow  the  plaster  to  be  moulded  into  some 
shape,  and  yet  soft  enough  to  permit  no  sharp  points  or  angles  on  its 
surface.  If  softer  than  this,  the  slightest  pressure  forces  it  out  of  the 
cup,  to  run  sometimes  out  of  the  mouth,  sometimes  on  the  tongue  and 
fauces.  This  also  is  apt  to  occur  if  an  excess  of  plaster  is  used. 
These  unnecessary  accidents  are  well  calculated  to  prejudice  patients 
against  plaster,  and,  perhaps,  against  the  operator. 

The  hardness  of  plaster  in  the  mouth  can  be  ascertained  by  the 
watch,  when  the  exact  time  required  for  setting  is  known,  or  by  testing 
some  of  the  plaster  remaining  in  the  bowl.  As  soon  as  it  breaks  with 
a  sharp  fracture,  it  should  be  removed.  To  keep  it  in  much  longer 
than  this  is  apt  to  give  unnecessary  pain  and  difficulty  in  removal, 
owing  to  the  absorbing  property  of  the  hardened  plaster,  which  causes 
it  to  cling  with  great  tenacity  to  the  mucous  membrane. 

Full  lower  impressions  are  generally  easy  to  withdraw ;  but  some 
full  upper  ones  adhere  very  tenaciously.  Raising  the  cheek  on  one 
side  or  in  front,  and  depressing  the  cup,  will  detach  most  cases.  This 
can  be  done,  in  case  of  plaster,  without  risk  of  injuring  the  shape  of 


714  MECHANICS. 

the  impression.  If  this  does  not  loosen  it  the  patient  maybe  requested 
to  give  a  slight  cough.  AVhere  there  is  much  undercut,  the  plaster 
Avill  break ;  but  it  can  readily  be  replaced.  Sometimes  the  action  of 
the  cheeks  and  lips,  or  of  the  soft  palate,  will  loosen  the  impression ; 
or  an  instrument  may  be  used  to  press  up  the  palate,  and  thus  cause 
air  to  pass  in  at  the  back,  when  it  may  be  easily  removed.  Compli- 
cated modifications  of  the  cup  to  facilitate  removal  are  of  little  value, 
and  make  an  unnecessary  multiplicity  of  apparatus. 

In  partial  cases,  the  outer  rim  (which  for  this  purpose  is  made  elastic, 
or  else  in  sections)  is  first  detached,  and  the  central  portion  then  loosened 
by  an  instrument  inserted  into  the  hach  part  of  the  gutta-percha  cup. 
If  there  should  be  many  broken,  detached  fragments,  either  loose  or 
caught  in  dovetail  spaces  between  the  teeth,  these  must  be  very  care- 
fully removed ;  and  when  the  surface  moisture  has  dried  off,  they 
must,  with  the  utmost  nicety,  be  replaced  in  the  impression.  This  is 
sometimes  a  tedious  and  difficult  operation ;  but  it  is  not  trouble  mis- 
appliect,  since  it  is  the  only  way  in  which  perfect  impressions  of  diffi- 
cult partial  cases  can  be  obtained.  Should  the  detached  plaster  be 
from  a  very  irregular  surface,  its  readjustment  is  made  much  easier  by 
touching  the  gutta-percha  at  that  point  with  a  camel's-hair  brush 
dipped  in  very  hot  water.  The  fragments  being  all  adjusted  and  the 
outside  ones  secured  by  a  little  resinous  cement,  should  there  be  much 
broken  surface  on  the  inside,  it  is  best  to  varnish  heavily  with  sanda- 
rach,  to  cement  the  pieces ;  otherwise,  let  the  surface  be  prepared,  as 
in  full  sets,  for  preventing  the  plaster  of  the  model  from  adhering. 

Wax  and  gutta-percha  require  nothing  for  this  purpose,  or,  at  most, 
a  very  thin  layer  of  oil.  Plaster  impressions  may  be  rendered  separ- 
able :  1,  by  an  alcoholic  varnish  of  sandarach  or  shellac,  or  a  diluted 
solution  of  soluble  glass,  with  a  little  oil  upon  the  varnished  surface 
when  dry ;  2,  by  saturating  it  with  as  much  oil  as  it  will  take  up  with- 
out standing  upon  its  surface ;  3,  by  coating  the  surface  with  a  dilute 
soap  mixture.  The  varnish  may  be  either  transparent  or  colored ;  the 
transparent  varnish  ■  consists  of  gum  sandarach,  I  v,  alcohol  Oij  ; 
the  colored  varnish  consists  of  the  same  proportions  of  gum  shellac 
and  alcohol.  The  gum  is  added  to  the  alcohol  and  digested  over  a 
moderate  heat  until  it  is  dissolved.  The  varnish  is  best  applied  with 
a  small  bristle  brush  ;  the  oil  and  soap  water  with  a  camel's-hair  brush 
or  a  stiflf,  pointed  feather.  The  varnish  must  be  kept  well  stopped,  or 
from  time  to  time  diluted,  so  as  not  to  become  thick.  The  soap  mix- 
ture needs  occasional  renewal,  as  the  plaster  gradually  neutralizes  its 
oil  and  renders  it  unfit  for  use. 

Some  dentists  take  plaster  impressions,  in  certain  cases,  thus  ;  First, 
a  wax  impression,  as  usual ;  then  enlarge,  by  pressure  or  by  cutting  out 


MATERIALS   FOR   IMPRESSIONS    OF   THE   MOUTH.  715 

the  depressions  formed  by  teeth  or  a  prominent  alveolar  ridge ;  lastly, 
they  pour  in  a  thin  layer  of  plaster,  and  repeat  the  impression.  Othei'S 
surround  certain  teeth  with  a  collar  of  wax,  preparatory  to  taking  a 
plaster  impression. 

The  last  is  a  troublesome  method,  very  apt  to  fail,  from  the  slipping 
of  the  wax  collars ;  nor  has  it  any  superiority  over  a  wax  impression, 
to  compensate  the  ti'ouble.  Dr.  C.  J.  Essig  suggests  the  following 
method  for  securing  a  plastic  impression  for  partial  cases :  "  An  im- 
pression should  first  be  selected  of  the  proper  size  and  shape  ;  those 
with  the  flat  floor  are  best  for  partial  cases ;  the  plaster  should  be 
mixed  thin,  almost  as  thin  as  water,  adding  chloride  of  soda  to  facili- 
tate setting.  Plaster  mixed  in  this  manner  does  not  become  hard  and 
unyielding  as  that  mixed  merely  to  saturation.  Now  oil  the  cup  so 
that  it  will  readily  separate  from  the  impression  when  hard,  fill  the 
cup  as  soon  as  the  plaster  thickens  sufficiently,  then,  with  a  small 
spatula,  place  a  layer  of  the  soft  plaster  in  upon  the  palatine  surface; 
otherwise  by  enclosing  the  air  in  the  deep  portion  of  the  arch  the  ac- 
curacy of  the  impression  may  be  impaired.  After  this  precaution,  the 
cup  is  placed  in  the  mouth,  and  gently  pressed  up  until  its  floor  comes 
in  contact  with  the  teeth.  When  the  plaster  is  sufficiently  hardened, 
remove  the  cup,  which,  from  its  having  been  oiled,  is  done  without 
difficulty;  with  the  thumb  and  index  finger  break  ofi"  the  outside 
walls ;  the  portion  covering  the  palatine  surface  is  then  removed  by 
the  use  of  a  blunt  steel  spatula,  curved  at  the  end  in  the  form  of  a 
hook.  The  pieces  are  then  placed  back  into  the  cup,  where  they  will 
be  found  to  articulate  with  perfect  accuracy.  Should  the  first  attempt 
be  rendered  futile,  by  the  tendency  to  nausea,  or  troublesome  gagging 
on  the  part  of  the  patient,  camphor  water,  as  recommended  by  Dr. 
Louis  Jack,  may  be  used  as  a  gargle,  which  will,  in  nearly  every  case, 
prove  an  eflfectual  remedy." 

The  comparative  value  of  the  four  impression  materials — wax, 
gutta-percha,  modeling  composition,  plaster — :can  only  be  determined 
by  a  careful  study  of  (1)  their  distinctive  peculiarities;  (2)  the  special 
requirements  of  difierent  mouths;  (3)  the  kind  of  base-plate,  and 
manner  of  its  construction.  The  exclusive  use  of  one  is  as  reprehen- 
sible as  the  indiscriminate  use  of  all.  No  one  is  best,  nor  can  any  be 
dispensed  with.  Disregard  of  this  most  important  fact  is  a  fruitful 
source  of  failure  in  impressions ;  failures  arising  neither  from  defect 
in  the  material  nor  lack  of  skillful  manipulation  in  the  operator,  but 
from  want  of  philosophical  selection  of  resources. 

(1)  Wax  demands  strong  pressure,  and  is  inelastic ;  also,  it  neither 
expands  nor  contracts  on  cooling.  It  copies  a  hard  gum  accurately, 
although  it  never  gives  the  fine  tracery  of  gutta-percha,  modeling 


716  MECHANICS. 

composition  or  plaster.  It  also  copies  a  soft  gum  ;  but  not  until  the 
gum  is  either  compressed  or  thrown  out  of  shape  by  the  strong  pres- 
sure required.  Gutta-Percha  requires  moderate  pressure ;  is  slightly 
elastic ;  also  has,  as  its  marked  peculiarity,  very  decided  contraction 
on  cooling,  which,  however,  is  under  control,  as  previously  explained. 
Slight  undercuts  it  will  take,  without  dragging,  as  wax  does ;  but,  on 
the  other  hand,  it  will  occasionally  pass  into  very  narrow  interdental 
spaces  and  injure  the  impression  in  the  effort  to  withdraw  therefrom. 
Modeling  Composition  ranks  next  to  plaster  as  an  impression  material, 
and  when  thoroughly  softened  in  boiling  water,  and  when  not  too  hot 
to  handle,  will  give  an  accurate  impression  under  strong  pressure,  and 
a  much  finer  tracery  than  wax.  Plaster  permits  only  gentle  pressure, 
taking  impressions  of  softest  tissues  in  natural  position.  It  slightly 
expands  in  setting ;  but,  in  a  rigid  cup,  this  makes  no  appreciable 
increase  in  the  size  of  the  model.  It  sets  so  hard  that  it  will  break 
before  leaving  the  smallest  undercut ;  but,  by  virtue  of  the  same 
quality,  it  can  be  used  in  the  most  marked  cases  of  dovetail,  or  alveolar 
undercut. 

(2)  Alveolar  and  palatine  surfaces,  and  their  investing  membranes, 
have  a  great  variety  of  conditions.  These  must  be  carefully  examined 
with  reference  to  the  properties,  just  named,  of  the  impression  materials. 
We  have  large  or  small  arches  ;  deep  or  flat  ones  ;  irregular  or  smooth 
ridges.  The  mucous  surfaces  may  be  uniformly  hard  or  soft ;  the  ridge 
hard  and  palate  soft,  or  the  more  difficult  combination  of  soft  ridge 
and  hard  palate ;  or  the  ridge  may  be  irregularly  hard  and  soft.  No 
one  material  can  possibly  be  equal  to  these  varying  conditions. 

(3)  The  mode  of  constructing  the  plate  will  often  determine  the 
choice  of  an  impression  material.  A  plate  swaged  upon  a  zinc  die  is 
smaller  by  the  shrinkage  of  the  die.  Here — apart  from  shape  or  hard- 
ness of  the  parts — plaster  would  be  best,  wax  next,  gutta-percha  the 
worst.  A  vulcanite  plate  is  larger  than  the  mouth,  by  the  expansion 
of  the  model.  Here,  the  contraction  of  gutta-percha  will  often  prove 
a  very  valuable  compensation  ;  also  the  compression  of  tissue,  made  by 
the  pressure  of  wax ;  special  considerations  must  determine  which  of 
these  to  choose  ;  but,  as  a  rule,  plaster  is  not  best  for  full  vulcanite  sets. 
On  the  other  hand,  plaster  is  best  for  all  partial  vulcanite  work,  and 
is  the  only  material  in  difficult  cases  worthy  of  any  reliance.  It  may 
safely  be  asserted  that  the  operator  who  cannot  take  an  accurate 
plaster  impression  of  any  partial  case,  however  difficult,  has  a  very 
imperfect  idea  of  the  value  of  hard  rubber.  For  the  majority  of  partial 
cases,  where  swaged  work  is  used,  wax  will  give  ample  accuracy. 
Where,  however,  the  undercut,  and  consequent  dragging  of  wax,  is 
very  great,  plaster  must  be  employed. 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH. 


717 


Fig.  526. 


Large,  or  hard,  or  irregular  mouths  are  best  copied  in  plaster;  great 
deviations  from  normal  size,  or  shape,  requiring  special  cups.  A  gum 
of  medium  softness,  but  uniform,  may  be  taken  equally  well  in  any 
material.  This  class  of  mouths  have  a  wonderful  adaptation  to  any 
thing  ;  variations  in  size  or  form  must  determine  the  selection  of  the 
material.  A  gum  of  extreme  softness,  yet  uniform,  will  give  better 
results  sometimes  with  one  material,  sometimes  with  another.  It  is 
often  very  difficult  to  determine  beforehand;  but,  in  case  of  failure, 
let  the  second  impression  be  taken  always  with  a  different  material. 
This  is  especially  true  of  lower  sets,  where  the  gum  behind  is  soft  and 
flexible ;  it  is  hard  to  say  whether  the  pressure  of  wax  or  the  softness 
of  plaster  leaves  the  ridge  in  best  condition  ;  gutta-percha  is  often  very 
useful  in  these  cases. 

Irregularity  of  texture  in  the  mucous  tissues  is  a  fruitful  source  of 
trouble.  A  hard  ridge,  with  a  soft 
palatine  surface,  is  easily  fitted,  and 
any  impression  material  may  be  used. 
But  the  reverse  condition  will  often 
require  the  firm  pressure  of  wax,  or 
modeling  composition  upon  the  ridge ; 
also  in  all  cases  of  inequality  of 
texture  in  the  ridge  itself.  As  a  rule, 
subject  to  exceptions,  wax  is  the  best 
for  these  mouths,  and  occasionally 
(especially  for  vulcanite)  the  contrac- 
tion of  gutta-percha  is  useful.  The 
old-fashioned  shape  of  upper  plates 
(Fig.  526)  will  often  give  the  best 

adhesion  and  most  useful  plates,  when  the  central  palate  is  very  hard. 
It  is  firmer  than  a  vacuum  cavity,  and  much  more  agreeable  to  the 
patient.  Of  course,  it  must  be  made  of  thick  plate,  to  give  requisite 
strength ;  doubling  the  plate,  as  far  as  the  bicuspids,  may  suffice. 

It  is  evident  that  an  enumeration  of  all  the  complications  which 
call  for  exercise  of  judgment  in  the  selection  of  impression  materials  is 
impossible.  By  suggesting  a  few  varieties,  we  hope  to  direct  attention 
to  a  much  neglected  point,  in  our  judgment  of  utmost  importance. 
Routine  practice,  which  inquires  into  the  reason  of  nothing,  and  the 
one-idea  system,  with  its  "priactice  makes  perfect"  motto,  are  equally 
at  fault.  The  future  may  reveal  some  new  material;  but  the  four  we 
now  have  are  alike  important  and  indispensable. 


718  MECHANICS. 

PLASTER  MODELS. 

The  model  is  made  of  calcined  plaster,  mixed  with  water  so  as  to 
have  the  consistence  of  cream ;  too  much  water  making  the  model 
fragile,  whilst  too  little  will  prevent  the  escape  of  the  air  contained  in 
the  plaster,  and  the  model  will  be  porous.  This  last  condition  also 
greatly  endangers  the  full  flowing  of  the  plaster  into  the  inequalities 
of  the  impression. 

The  model,  for  convenience  of  description,  is  said  to  have  a  face, 
back,  body  and  sides — terms  scarcely  requiring  explanation.  The  face, 
corresponding  with  the  mouth  to  be  fitted,  requires  greatest  care ;  and 
the  same  directions  answer  for  it  in  all  models.  The  body  of  the 
model  has  different  shape  and  size  according  to  the  use  to  be  made  of 
it.  The  back  should  be,  in  all  cases,  parallel  with  the  face.  The  sides 
are  to  be  either  vertical  or  slanting,  according  to  its  uses. 

In  making  models,  we  require  a  plaster  table,  with  a  rim  to  prevent 
scattering  of  waste  plaster;  having  at  least  two  drawers  in  front,  a 
shelf  at  the  back,  also  an  opening  for  escape  of  Avaste  plaster  into  a 
refuse  box ;  a  tight  plaster  can  and  a  bucket  of  water  will  complete 
the  outfit  of  the  table.  The  implements  are  two  or  three  strong  bowls, 
a  plaster  scoop,  a  spatula,  an  iron  spoon,  a  plaster  knife,  a  scraper,  a 
sponge  and  some  camel's-hair  brushes  or  wing  feathers  of  poultry. 
Sometimes  a  marble  slab  or  slate  is  used  for  shaping  the  back  of  the 
model  upon  ;  but  if  the  table  is  kept  clean  and  smooth  with  the 
scraper,  this  is  not  essential ;  since,  in  any  case,  a  piece  of  wet  paper 
should  be  laid  down,  to  permit  the  ready  removal  of  the  model,  for 
the  purpose  of  shaping,  whilst  yet  rather  soft.  Running  water  and 
waste  pipes  are  apt  to  become  more  a  nuisance  than  an  advantage  to 
a  plaster  table ;  because  the  latter  are  so  apt  to  become  closed  by 
the  careless  use  of  plaster.  A  bucket  of  water,  changed  daily,  is 
equally  good,  and  has  the  merits  of  simplicity  and  universal  applica- 
bility. 

The  most  troublesome  models  are  the  thick  ones  for  sand  moulding. 
The  surface  of  the  impression  being  prepared  as  above  directed,  the 
cup  is  surrounded  with  a  rim  of  wax,  waxed  cloth,  sheet  lead  or  tin 
foil,  fitting  closely,  to  prevent  escape  of  plaster,  and  about  two  inches 
deep.  The  rims  should  be  slightly  curved,  to  give,  Avhen  placed 
around  the  cup,  the  requisite  flare.  Models  made  in  such  rims  need 
trimming  with  the  knife.  To  avoid  this,  and  also  to  give  greatest 
possible  smoothness  and  regularity  to  the  sides,  flaring  rings  of  sheet 
tin  may  be  used  as  follows.  Set  the  impression  level  on  the  table,  and 
surround  with  some  soft  plastic  material  (wet  newspaper  made  into  a 
pulpy  mass  is  perhajjs  the  most  convenient),  and  into  this  set  a  ring 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH. 


719 


of  such  size  as  will  give  a  proper  shoulder  to  the  model.  Fig.  527 
shows  such  a  ring  arranged  for  making  such  a  cheoplastic  model.  For 
a  sand  model,  the  ring  should  flare,  should  conform  more  to  the  shape 
of  the  cup,  and  be  smaller.  For  the  dipping  process  of  making 
counter-dies  and  dies,  the  model  needs  no  specially  nice  trimming. 
For  the  fusible-metal  process,  the  model  should  be  cylindrical,  and  not 
flaring.     These  are  the  three  forms  of  thick  or  deep  model. 

The  shallow  models  are  usually  made  without  rims.  The  impression 
is  filled,  then  turned  down,  when  the  plaster  has  set  sufficiently  to 
permit  it,  on  the  remaining  plaster,  and  poured  on  a  strip  of  wet  paper. 
Whilst  plastic  it  is  shaped  with  the  spatula.  If  for  vulcanite  or  other 
plastic  work,  it  is  taken  up  while  soft  enough  to  dress  with  the  sponge. 

Fig.  527. 


But  if  the  shallow  model  is  to  be  used  in  sand  moulding,  or  in  Dr. 
Gunning's  process,  it  is  allowed  to  harden  and  is  then  trimmed  with 
the  knife.  In  vulcanite  models  it  will  save  time  and  insure  greater 
accuracy  in  articulation,  to  extend  the  model  at  once  and  make  the 
articulating  portion,  as  will  be  fully  explained  when  describing  the 
process  of  articulation.  The  sides  of  vulcanite  models  need*  no 
shaping,  except  such  as  neatness  and  convenience  in  handling  require ; 
since  they  are  subsequently  set  into  the  flask ;  but  they  should  be  no 
larger  or  thicker  than  strength  requires. 

When  rims  are  used,  the  impression  should  rest  upon  the  plaster 
table ;  if  set  level,  the  back  will  necessarily  be  parallel  with  the  face, 
since  the  thin  plaster  poured  into  the  rim  finds  its  level.     In  making 


720 


MECHANICS. 


shallow  models,  the  impression  is  held  iu  the  hand,  thus  permitting  the 
flow  of  the  plaster  to  be  aided  by  moving  or  tapping  it.  As  before 
stated,  wax  and  gutta-percha  need  no  oiling ;  plaster  may  be  oiled  or 
soaped,  or  else  varnished  and  oiled ;  it  must  also  be  saturated  with 
water  just  before  pouring  the  model. 

Calcined  plaster  for  models  should  not  set  too  rapidly,  as  this  will 
cause  haste,  with  its  attendant  dangers.  Coarse  plaster  makes  a  stronger 
model,  but  it  has  greater  expansion.  Gum-water,  or  size,  retards  the 
setting,  but  makes  the  model  very  hard ;  salt  quickens  the  setting, 
but  should  not  be  used  for  any  models  which  are  to  be  kept  as  per- 
manent records  of  the  case.  It  is  best  to  add  the  plaster  to  the  water, 
than  the  reverse ;  it  makes  smoother  work  by  permitting  the  escape 
of  the  air ;  it  also,  by  the  amount  of  unsaturated  plaster,  permits  the 
operator  to  gauge  the  stiffness  of  the  batter.  Yet  practiced  operators 
may  with  equal  success  add  water  to  the  plaster. 


Fig.  528. 


Fig.  529. 


In  all  cases  the  face  of  the  model  is  the  part  first  made.  The  thin, 
freshly-mixed  plaster  is  first  to  be  carefully  run  into  the  depressions 
of  the  teeth  or  their  ridges.  A  brush  or  feather  is  necessary  when  the 
cup  is  stationary ;  when  in  the  hand,  motion  or  tapping  will  cause  the 
plaster  to  flow  as  desired.  Perhaps  the  surest  way  to  prevent  defects 
on  the  face,  from  confined  air,  is  to  have  a  little  surplus  water  in  the 
cup.  The  plaster  (which  in  this  case  must  not  be  too  thin)  settles  at 
once  into  the  smallest  crevice  under  the  water,  and,  if  not  stirred,  it 
will  not  be  made  thin  and  rotten  by  it. 

The  impression  once  filled,  the  formation  of  the  body  is  easy.  For 
deep  models,  the  remaining  plaster  should  be  poured  at  once,  that, 
while  thin,  it  may  form  a  smooth  and  level  back.  For  shallow  models 
the  plaster  must  slightly  stiffen,  lest  the  weight  of  the  impression 
should  make  it  settle  too  much  into  the  plaster  on  the  table.  The  sponge 
is  very  useful  iu  dressing  up  a  model ;  it  cuts  more  or  less  according 
to  the  state  of  the  plaster.     It  may  be  used  to  trim  vulcanite  models 


MATERIALS   FOR   IMPRESSIONS   OP  THE   MOUTH. 


721 


Fig.  580. 


LEAD 


directly  after  the  spatula,  or  to  give  finish  to  other  models  after 
the  use  of  the  knife.  But  when  jilaster  is  fully  hardened  it  has  no 
effect. 

Figs.  528  and  529  represent  upper  and  lower  models  suitable  for 
sand  moulding ;  the  same  may  be  used  for  dipping.  Fig.  530  repre- 
sents a  shallow  model  in  the  moulding  flask,  show- 
ing how  the  body  of  the  die  is  formed  by  the  zinc- 
half  of  the  flask.  The  same  figure  may  be  taken 
to  represent  the  position  of  the  thin  model  at  the 
bottom  of  an  iron  cup,  in  the  process  of  making 
the  counter-die  by  Dr.  Gunning's  method. 

Difficulties  arising  from  undercuts,  on  the  outside 

of  the  upper  ridge  and  on  the  inside  of  the  lower,        ' " 

may  be  overcome :  (1)  by  filling  up  the  undercut  with  wax  or  plaster 
in  all  places  where  it  is  unnecessary  or  impracticable  to  carry  the 
metallic  plate  ;  (2)  by  using  a  peculiarly-constructed  flask  for  mould- 
ing, such  as  the  one  invented  by  Dr.  G.  E.  Hawes  (Figs.  536,  538) ; 
(3)  by  filling  the  undercut  with  movable  pieces  of  plaster,  technically 
known  as  "  false  cores."  They  should  be  shaped  so  as  to  admit  of  being 
drawn  from  the  sand ;  at  the  same  time  they  must  have  a  decided 
angle,  so  as  to  mark  distinctly  the  place  in  the  sand  for  their  replace- 
ment. A  small  nail  or  tack  in  the  sand,  above  the  core,  will  keep  it 
in  place  while  the  metal  is  being  poured.  (4)  By  making  a  sec- 
tional model  (Fig.  531),  as  suggested  by  Dr.  A.  Westcott.  It  may 
be  made  by  filling  the  central  third  of  the  wax  impression  with  the 
plaster,  keeping  it  from  the  lateral  thirds  by  a  temporary  use  of  clay 
or  putty.  This  is  removed  and  trimmed,  leaving  the  back  wider  than 
the  face  (Fig.  531)  ;  then  replaced  in  the  impression,  and  filled  up  on 


Fig.  531. 


722 


MECHANICS. 


Fig.  532. 


each  side  with  plaster ;  the  model  is  then  removed,  properly  trimmed 
and  varnished. 

Dr.  Bean's  method  of  making  a  model  in  two  parts  is  equally  appli- 
cable to  making  models  in  three  parts,  and  is  perhaps  better  than  the 
foregoing.  He  thus  describes  it.  "  To  secure  a  division  in  the  model 
itself,  the  best  plan  is  to  set  up  in  the  impression  a  septum  of  thin 
sheet  lead,  forming  a  vertical  plane  in  the  median  line  of  the  palate, 
and  fitted  somewhat  to  the  inequalities  of  the  impression.  This  plate 
should  have  two  or  three  small  projections  struck  up  on  one  side,  by 
means  of  a  small  conical  punch,  and  the  opposite  side  has  some  cotton 
fibre  attached  with  shellac,  in  the  manner  described  for  preparing  im- 
pression cups.  Fig.  532  represents  the  shape  of  this  plate  (one-half 
the  size),  and  shows  the  side  on  which  are  the  projections. 
Its  proper  position  will  be  readily  understood  when  ap- 
plied to  an  impression  of  one  of  those  deep  palates  now 
under  consideration.  The  side  having  the  projections  is 
oiled,  the  cotton  on  the  other  side  wet  with  water,  and 
while  filling  up  the  impression,  this  plate  is  set  up  in  the 
middle,  along  the  median  line,  so  that  when  the  model  is 
trimmed  to  proper  size  and  shape,  it  may  be  carefully 
broken  apart  and  placed  together  again,  in  the  same  posi- 
tion." 

Much  time  may  be  wasted  in  the  efibrt  to  overcome 
difiiculties  of  undercut  in  sand  moulding.  The  dexterous  removal  of 
shallow  models  will  suffice  for  most  cases  of  front  undercut ;  and  of 
all  others,  it  may  be  said  that  no  undercut  on  the  die  is  of  any  ser- 
vice into  which  the  plate  cannot  be  swaged,  or  in  removal  from  which 
the  plate  is  apt  to  be  bent. 

Reraoving  the  impression  is  a  fruitful  source  of  vexation,  because 
of  the  frequent  breaking  of  prominent  parts  of  the  model,  and  other 
annoying  accidents.  But  these  are  in  every  case  the  result  of  haste, 
carelessness,  or  forgetfulness.  First,  the  model  must  have  time  to 
harden  ;  then  the  impression,  if  of  wax  or  gutta-percha,  must  be 
thoroughly  softened.  The  common  practice  of  setting  the  model  on 
the  stove  is  bad  ;  the  smell  of  burning  wax  is  often  the  first  warning 
of  a  softening  which  has  gone  too  far,  injuring  the  model  by  the  ab- 
sorption of  melted  wax.  It  is  far  better  to  place  it  in  water  at  140° 
and  150°  Fahrenheit,  leaving  it  long  enough  for  the  entire  mass  of 
wax  to  soften :  at  this  temperature  the  wax  does  not  melt,  yet  is  so  soft 
that  it  cannot  injure  the  most  delicate  point  of  the  model.  If  over 
150°,  some  portions  may  adhere  to  the  model,  and  give  trouble  in 
removing.  Gutta-percha  impressions  must  be  thoroughly  softened  in 
water  at  200°  ;  if  over  this  temperature,  portions  of  gutta-percha  are 


MATERIALS   FOR   IMPRESSIONS   OF   THE   MOUTH.  723 

apt  to  adhere  to  the  surface.  In  partial  cases,  it  is  a  good  plan  to  first 
remove  the  cup,  then  turn  up  the  edges  of  softened  wax  or  gutta- 
percha, till  it  is  free  from  the  teeth,  and  then  remove  the  entire 
mass. 

Plaster  impressions  require  a  different  treatment.  If  the  cup  is 
wholly  or  partly  of  wax  or  gutta-percha,  these  must  first  be  softened 
and  removed :  a  Britannia  cup  is  loosened  by  light  strokes  of  the 
plaster  knife  handle.  The  impression  is  then  broken  away  piecemeal. 
Dipping  it  in  hot  water  makes  it  rotten,  and  facilitates,  at  times,  its  re- 
moval. It  is  often  necessary  to  cut  nearly  through  the  impression  in 
places ;  in  doing  which,  the  knife  or  graver  must  be  held  so  as  to 
guard  against  injury  to  the  model  beneath.  Another  safeguard  is  to 
coat  the  impression,  before  pouring,  with  oil  colored  by  alkanet ;  or, 
better  still,  to  tinge  the  plaster  with  which  the  impression  is  taken 
Avith  Vermillion  or  Brandon  red ;  it  gives  the  dry  plaster  a  faint 
pinkish  tinge;  does  not,  in  this  small  proportion,  injure  its  setting 
qualities ;  and  it  makes  a  very  distinct  contrast  with  the  pure  white  of 
the  model. 

Few  impressions  can  be  used  twice;  those  taken  in  wax  or  gutta- 
percha cups  never.  Partial  impressions  of  all  kinds  are  necessarily 
sacrificed  to  the  integrity  of  the  first  model.  But  plaster  impressions, 
in  a  smooth  Britannia  cup,  may,  with  proper  care,  be  replaced  in  the 
cup,  and  used  again  so  as  to  give  a  model  quite  equal  to  the  first. 
Some  of  these  will  come  from  the  model  entire ;  but  often  it  is  neces- 
sary to  cut  a  groove  over  the  alveolus,  and  break  ofi"  the  outer  rim  in 
two  or  three-sections. 

Models  are  mostly  trimmed  before  removing  the  impression  ;  but  it 
is  always  necessary  afterward  to  trim  the  shoulder.  Usually  this  is 
done  by  merely  taking  off"  the  rough  edges,  following  the  outline  of 
the  edge  of  the  impression;  but  for  striking  up  a  plate  with  the  outer 
edge  turned  up,  a  flange,  or  shoulder,  about  the  fourth  of  an  inch  wide, 
is  formed  around  the  outside  of  the  plaster  model,  where  it  is  designed 
that  the  edge  of  the  base  plate  shall  terminate  on  the  alveolar  border. 
It  may  be  shaped  either  in  wax  or  plaster,  and  should  stand  off  from 
the  ridge  at  an  angle  of  about  90°  or  100°,  the  angle  of  the  rim  being 
completed  with  pliers  after  swaging.  A  plate  swaged  with  such  a  rim 
is  used  in  mounting  gum  or  block  teeth,  and  in  continuous  gum  work; 
it  is  stronger  than  a  simple  plate,  and  is  susceptible  qf  a  more  beautiful 
finish.  For  a  lower  set  of  block  teeth,  the  edge  of  the  plate  may  also 
be  turned  up  all  the  way  round.  An  objection  to  a  swaged  rim  is  the 
occasional  difficulty  of  determining  just  how  far  over  the  ridge  the 
plate  should  extend ;  for  any  change  is  impossible  without  destroying 
the  rim.     Hence  the  more  common  practice,  except  in  continuous  gum 


724  MECHANICS. 

work,  is  to  solder  a  gold  band  or  wire,  after  adaptation  of  the  plate  to 
the  mouth,  as  hereafter  explained. 

The  model,  if  it  is  to  be  used  in  sand  moulding,  should  have  several 
coats  of  shellac  or  sandarach  varnish  applied  with  a  small  bristle 
brush,  to  give  it  a  smooth,  hard  and  polished  surface.  This  will  pro- 
tect it  from  injury  by  use,  render  it  more  pleasant  to  handle,  and  cause 
the  sand  to  part  easily  from  it.  The  gum  shellac  varnish  may  be  pre- 
pared by  dissolving  five  ounces  of  shellac  in  one  quart  of  alcohol.  In 
using  this  varnish  on  a  damp  impression,  be  careful  not  to  apply  a 
second  coat  until  the  first  is  hard ;  else  it  will  cause  the  first  to  peel, 
and  injure  the  smoothness  of  the  surface.  Sandarach  varnish  is  pre- 
ferable to  shellac,  as  it  is  harder;  it  is  also  more  transparent,  and, 
consequently,  does  not  color  the  plaster.  It  may  be  made  in  the  fol- 
lowing manner :  Take  six  ounces  of  gum  sandarach,  one  ounce  of  elemi ; 
digest  in  one  quart  of  alcohol,  moderately  warm,  until  dissolved ;  or 
the  sandarach  alone  may  be  used.  This  is,  perhaps,  as  good  a  varnish 
as  can  be  used  for  plaster  models.  It  is  easily  prepared,  but  the  alcohol 
should  be  warmed  in  a  sand  bath  or  hot  water,  to  prevent  it  from  taking 
fire.  To  make  the  finest  varnish^  the  sandarach  should  be  of  best 
quality,  and  washed  in  water  before  being  put  into  the  alcohol.  Some, 
however,  prefer  a  coating  of  charcoal  dust  or  plumbago  for  sand 
models. 

Models  for  dipping,  or  pouring,  or  the  fusible-metal  process,  should 
have  no  kind  of  varnish  upon  them.  Vulcanite  and  other  plastic  work 
models  may  have  a  protecting  coat  of  dilute  soluble  glass  (nine  parts 
water  to  one  part  of  the  glacial  syrup) ;  but  if  too  much  or  too  strong 
a  solution  is  used,  it  will  do  more  harm  than  good. 


CHAPTER  IX. 

DIES   AND    COUNTER-DIES — SWAGING   PLATES. 

yARIOUS  methods  have  been  adopted  for  procuring  metallic  4ies 
and  counter-dies.  The  three  following  are  all  which  the  autnor 
deems  it  necessary  to  describe.  The  first  of  these  consists  in  pouring 
melted  metal  into  a  mould  or  matrix,  made  in  sand  with  the  plaster 
model.  By  this  means  the  die  is  formed,  and  the  counter-die  is  obtained 
by  pouring  metal  upon  it.  The  second  consists  in  making  the  counter- 
die  first,  either  by  immersing  the  plaster  model  in  metal,  or  pouring 
metal  upon  it;  the  die  is  formed  by  pouring  metal  into  this. 


DIES   AND   COUNTER-DIES — SWAGING   PLATES.  725 

The  third  consists  in  pouring  the  metal  for  the  metallic  die  directly 
into  the  impression.  A  very  ingenious  set  of  flasks  for  this  purpose, 
the  invention  of  Dr.  F.  Y.  Clark,  can  be  had  at  the  dental  depots. 
The  same  may  be  done,  less  conveniently  perhaps,  with  the  usual 
Britannia  cups  and  moulding  rings.  Take  a  piece  of  copper  or  brass 
gauze,  and  fit  into  the  cup  before  taking  the  impression.  Set  the 
impression,  thus  strengthened,  into  a  batter  (asbestos  or  sand  three 
parts,  plaster  one  part),  poured  into  a  narrow  iron  ring  (sheet  iron  will 
answer) ;  carefully  work  the  batter  around  the  edges  of  the  impression  ; 
then  place  upon  it  the  zinc  half  of  Bailey's  flask 
(Fig.  533).     If  the  impression  is  thoroughly  dried,  ^^^-  ^^"'^• 

the  first  metallic  die  will  be  perfect,  no  matter  how 
much  undercut  there  may  be.  A  second  or  third 
may  then  be  taken,  more  or  less  defective,  but  very 
useful  for  the  first  stages  of  the  swaging  process. 
Zinc  is  the  metal  used  by  Dr.  Clark  for  the  die. 
In  this  process  the  impression  may  be  plaster  or  plaster  and  feldspar ; 
but  the  investing  batter  should  have  only  enough  plaster  to  bind  the 
asbestos  or  sand  together.  Dr.  Clark  uses  a  copper  impression  cup, 
which  Prof.  Austen's  process  dispenses  with.  The  flask  and  impression 
must  be  perfectly  dry,  and  heated  nearly  or  quite  up  to  the  fusion 
point  of  the  metal  used. 

The  second  method  admits  of  three  modifications:  1.  The  fusible- 
metal  process ;  in  which  the  model  is  surrounded  with  thick  paper,  and 
fusible  metal,  in  a  semi-fluid  state,  is  dashed  over  it  with  a  spoon,  the 
model  being  cold,  so  as  to  rapidly  chill  the  metal.  While  still  warm, 
the  paper  is  removed,  and  the  counter-die  trimmed  with  a  knife;  for  at 
this  temperature  it  can  be  cut  as  readily  as  cheese.  The  counter-die, 
when  cold,  is  then  smoked  or  coated  with  whiting,  surrounded  with 
paper,  and  semi-fluid  fusible  metal  dashed  on  it,  to  make  the  die.  This 
process  is  repeated,  until  from  two  to  six  dies  are  made,  according  to 
the  irregularity  of  the  case.  The  model  should  be  made  in  a  ring  of 
nearly  circular  shape  and  cylindrical ;  it  should  also  be  at  least  half 
an  inch  larger  than  the  alveolar  ridge,  that  the  counter-die  may  have 
sufficient  metal  to  force  up  the  plate. 

2.  The  dipping  process  consists  in  pouring  melted  lead,  type-metal, 
or  pewter  into  a  sheet-  or  cast-iron  cup  or  box,  three  and  a  half  or  four 
inches  in  diameter,  and  three  or  four  inches  deep,  until  it  is  more  than 
half  full :  then,  stirring  the  fluid  mass  with  gradually  increasing 
rapidity  until  it  begins  to  granulate,  quickly  brush  oflf  the  surface 
dross,  and  at  once  immerse  the  plaster  model  more  or  less  deeply,  as 
the  palate  is  a  deep  or  shallow  one,  and  hold  it  there  until  the  metal 
congeals.     To  prevent  accident  from  air  confined  in  the  palatine  arch, 


726  MECHANICS. 

a  small  hole  should  be  drilled  through  the  plaster  model.  It  is  then 
removed,  and  the  whole  upper  surface  of  the  counter-die  covered  with 
a  thin  coating  of  whiting  or  lamp  smoke,  as  before  directed.  After  this 
has  become  perfectly  dry,  melted  block  tin,  type  metal  or  soft  solder, 
at  a  temperature  so  low  that  it  will  not  char,  or  even  discolor  white 
paper,  is  poured  in,  until  the  cup  is  filled.  If  the  counter-die  is  so 
deep  that  the  die  has  not  sufficient  thickness,  it  may  be  deepened  by 
placing  on  the  freshly-poured  metal  the  zinc  half  of  a  Bailey  flask,  and 
continuing  to  pour  ;  the  metal  in  the  two  flasks  will  unite  and  form 
one  die.  When  cold,  the  castings  are  removed  from  the  iron  cup, 
separated,  and  are  then  ready  for  use. 

3.  Dr.  Gunning's  method,  called  also  the  "  pouring  process,"  in  which 
a  very  thin  model  (made  of  plaster  two  parts,  and  sand  or  feldspar  one 
part)  is  placed  in  the  bottom  of  an  iron  box,  three  and  a  half  to  four 
inches  in  diameter,  and  about  two  inches  deep.  It  is  fastened  there 
by  a  thin  layer  of  plaster  and  sand,  then  thoroughly  dried  by  gradually 
raising  box  and  all  to  the  temperature  of  the  melted  metal,  which  is 
next  poured  in,  and  the  box  set  in  a  shallow  vessel  of  water  to  cool  it 
rapidly  from  the  outside.  To  delay  the  cooling  in  the  centre  until 
the  last  moment,  and  so  prevent  contraction  at  that  place,  a  very  hot 
pointed  iron,  somewhat  similar  in  shape  and  size  to  a  tinner's  soldering 
iron,  is  placed  upon  the  centre  of  the  model  before  the  metal  is  poured. 
When  cold,  this  is  removed,  and  the  conical  space  filled  with  metal. 
The  counter-die  is  thus  made  of  lead,  alloyed  with  tin  or  type  metal. 
The  die  is  made  by  placing  over  this  a  stout  wrought  iron  ring,  and 
pouring  in  fusible  metal.  Dr.  Gunning  uses  from  three  to  eight  dies, 
according  to  the  sharpness  of  the  prominences  of  the  model.  The 
method  gives,  in  his  hands,  very  accurately  fitting  plates. 

When  metallic  dies  are  to  be  obtained  by  the  first  method,  moulding 
flasks  and  sand  are  required.  Flasks  may  be  of  wood  or  iron.  The 
moulding  box  of  wood  should  be  about  six  inches  square.  This  is  to 
be  filled  with  fine  sand,  such  as  is  used  by  brass  founders,  in  the  fol- 
lowing manner:  The  deep  or  shallow  plaster  model  is  placed  on  the 
moulding  table,  exactly  in  the  centre  of  the  box,  with  its  face  upward. 
Sand  is  then  firmly  packed  around  the  sides  of  the  model.  Sand 
should  then  be  sifted,  covering  the  face  of  the  model  to  the  depth  of  a 
half  inch,  the  box  then  filled,  and  the  whole  rammed  with  a  firmness 
proportioned  to  the  coarseness  or  dryness  of  the  sand — damp  or  very 
fine  or  strong  (i.  e.,  with  large  percentage  of  clay)  sand  not  permitting 
so  much  compression  as  sand  possessing  the  opposite  qualities,  because 
it  would  become  too  compact  to  permit  the  escape  of  the  vapors  formed 
during  the  process  of  pouring.  But  the  finest  sand,  rich  in  clay  and 
quite  moist,  may  be  used,  if  it  is  dried  before  pouring. 


DIES   AND   COUNTER-DIES — SWAGING   PLATES. 


727 


The  box  is  then  turned  over  and  gently  tapped  several  times  with 
some  light  instrument  or  hammer,  for  the  purpose  of  starting  or 
detaching  it  a  little  from  the  matrix,  and  then  carefully  removed. 
Great  care  is  necessary  that  this  tapping  does  not  depress  first  one 
side  and  then  the  other;  this  would  make  the  die  too  deep  in  the 
centre,  and  perhaps  cause  the  plate  to  rock.  The  model  may  be 
loosened  laterally,  by  holding  an  excavator  firmly  upon  the  centre 
of  the  die  and  tapping  it  on  the  side.  If  the  model  be  composed  of 
three  pieces,  the  middle  section  is  first  removed,  and  afterward  the 
two  others.  There  are  two  ways  of  drawing  the  model :  first,  by 
screwing  into  it  an  excavator  or  gimlet,  and  carefully  drawing  it  out ; 
second,  by  throwing  it  out  with  a  dexterous  jerk  of  the  matrix.  The 
last  is  best ;  the  excavator  is  apt  to  break  through  the  centre  of  the 
thin  model,  and  the  thick  one  falls  out,  by  its  own  weight,  better  than 
it  can  be  drawn.  Fig.  534  represents  the  two  ends  of  a  double 
spatula,  which  will  be  found  very  useful  in  sand  moulding. 

Fig.  534. 


If  the  deep  model  is  used,  the  matrix  is  now  ready  for  pouring ;  but 
first  remove  all  loose  sand,  and  make  a  groove  at  the  back  part  of  the 
matrix  to  receive  the  first  flow  of  the  metal.  If  the  thin  model  is 
used,  a  ring  must  be  set  upon  the  sand  after  the  model  is  drawn,  to 
give  the  additional  size  which  the  die  requires  to  prevent  cracking 
under  the  swaging-hammer. 

The  mould  being  prepared,  the  metal  to  be  employed  for  the  casting 
should  be  put  into  a  tolerably  thick  wrought-  or  cast-iron  ladle,  and 
melted  in  a  common  fire  or  furnace.  Mr.  Fletcher  has  invented  a  very 
useful  melting  apparatus,  which  is  also  suitable  for  drying  and  boiling 
purposes.  If  brass  is  used,  a  blast  furnace  will  be  required  to  melt  it; 
but  if  zinc,  block  tin  or  lead,  a  common  fire  will  afford  sufficient  heat. 
As  soon  as  the  metal  has  become  thoroughly  melted,  it  is  poured  into 
the  furrow  formed  in  the  sand,  whence  it  will  flow  into  the  back  part  of 
the  mould.     It  is  necessary  to  convey  the  melted  metal  into  the  mould 


728 


MECHANICS. 


in  this  way  to  prevent  the  injury  which  the  surface  of  the  sand  might 
sustain  by  pouring  directly  upon  it. 

There  have  been  quite  a  number  of  moulding  flasks  devised  to  super- 
sede the  wooden  one  just  described,  or  the  common  cart-wheel  box, 
which  was  once  much  used.  Some  of  these  are  worse  than  useless ; 
others  are  very  convenient,  and  have  the  advantage  of  requiring  only 
a  small  quantity  of  sand;  also  of  permitting  the  sand  to  be  dried, 
which  cannot  be  well  done  in  the  wooden  box.  The  simplest,  and 
perhaps  best,  flask  is  that  invented  by  Dr.  E.  N.  Bailey.  Fig.  535 
represents  the  shape  and  working  of  this  flask. 

Half-flask  b  is  placed,  joint  edge  downward,  over  a  thin  model,  and 
firmly  packed  with  sand.  It  is  then  turned;  the  sand  compressed 
around  the  edge  of  the  model ;  then  trimmed  so  that  the  model  may 
be  easily  drawn  (a  properly  shaped  model  renders  much  sand  trimming 
unnecessary)  ;  the  model  is  then  lightly  tapped  and  thrown  out.  All 
operations  on  the  thin  model  must  be  conducted  with  great  care,  for 
it  is  easily  displaced  in  its  matrix,  so  as  to  destroy  the  accuracy  of  the 


LEAD 


latter.  Next,  pour  zinc  into  the  mould,  and  at  once  place  on  half- 
flask  A,  and  complete  the  pouring.  When  cool,  remove  the  sand,  in- 
vert the  flask,  with  zinc  die  contained,  and  pour  the  lead  (c)  upon  the 
zinc  for  the  counter-die. 

In  cases  of  moderate  undercut  in  front,  the  thin  model  can  generally 
be  drawn  by  a  dexterous  backward  movement.  But  for  a  deeper 
undercut  in  front,  also  for  those  at  the  side,  the  moulding  flask  of  Dr. 
Hawes  (Figs.  536,  537,  538)  will  be  found  useful.  In  Fig.  536  the 
lower  section  of  the  flask  is  slightly  opened,  to  show  joints.  In  Fig. 
538  the  upper  section.  In  Fig.  537  the  lower  section  is  closed  and 
confined  by  a  pin,  with  the  plaster  model  placed  in  it. 

The  manner  of  using  it  is  thus  described  by  Dr.  C.  C.  Allen :  "  If 
the  model  be  considerably  smaller  than  the  space  between  the  flanges 
projecting  inward,  small  slips  of  paper  may  be  placed  in  the  joint, 
extending  to  the  sides  of  the  model,  so  as  to  part  the  sand  when  open- 
ing the  flask  for  the  removal  of  the  pattern.  The  sand  may  now  be 
packed  around  the  model  up  to  the  most  prominent  part  of  the  ridge. 


DIES   AND   COUNTEE-DIES — SWAGING   PLATES. 


729 


It  should  be  finished  smoothly  around  it,  slightly  descending  toward 
the  model,  so  as  to  form  a  thick  edge  of  sand  for  the  more  perfect 


Fig.  536. 


Fig.  537. 


Fig.  538.  parting  of  the  flask.     The  sand  and  face 

of  the  model  must  now  be  covered  with  dry 
pulverized  charcoal,  sifted  evenly  over  the 
whole  surface.  When  this  is  done,  the  upper 
section  of  the  flask  is  placed  over  the  lower 
and  carefully  filled  with  sand.  It  is  then 
raised  from  the  lower  one,  which  may  now 
be  parted  by  removing  the  long  pin,  and  the  model  gently  taken  away. 
When  closed,  and  the  two  put  together  again  and  inverted,  it  is  ready 
to  receive  the  melted  metal."  After  the  metal  has  cooled,  it  may  be 
removed  and  turned  over,  so  that  the  face  of  the  die  shall  be  upward, 
while  the  remainder  is  buried  in  the  sand.  Thus  placed,  it  is  encircled 
with  the  ring  (Fig.  538),  and  the  metal  for  the  counter-die  poured 
upon  it. 

The  metals  most  commonly  used,  when  metallic  dies  are  made  by 
sand  moulding,  are  zinc  and  lead.  For  many  reasons,  these  are,  per- 
haps, the  best  metals  for  general  use  that  can  be  employed.  Zinc  is 
the  hardest  metal  that  the  dentist  can  conveniently  melt.  In  case  of 
deep  or  large  arches,  and  for  mouths  where  the  mucous  membrane  is 
very  hard,  should  its  shrinkage  prevent  the  close  adaptation  of  the 
plate,  a  finishing  die  may  be  made  of  block  tin,  type  metal,  soft  solder, 
or  Babbit's  metal  (a  patented  alloy  of  copper,  tin  and  antimony,  which 
can  be  obtained  at  any  machine  shop),  which  last  is  nearly  as  hard  as 
zinc,  and  has  decidedly  less  shrinkage.  When  a  metal  softer  than  zinc 
is  used,  several  dies  will  be  necessary,  to  complete  the  swaging. 

Prof.  Austen,  by  careful  experiment,  found  that  an  average-sized 
zinc  die,  measuring  two  inches  transversely,  contracts  to^^  of  an 
inch  from  outside  to  outside  of  the  alveolar  ridge,  being  equivalent  in 
thickness  to  three  ordinary  book  leaves.  He  remarks :  "  In  the  first 
case  (upper  jaw),  the  plate  would  '  bind,'  and  if  the  ridge  were  covered 
by  an  unyielding  mucous  membrane,  it  would  prevent  accuracy  of 
adaptation.     In  the  second  case  (under  jaw),  the  plate  would  have 


730 


MECHANICS. 


too  much  lateral  'play,'  and  consequently  lack  stability.  Again,  in  a 
moderately  deep  arch,  say  half  an  inch  in  depth,  the  shrinkage  between 
the  level  of  the  ridge  and  the  floor  of  the  palate  will  be  nearly  Wxm 
— rather  more  than  one  leaf.  In  the  deepest  arches  this  shrinkage 
may  give  trouble,  except  where  the  ridge  is  soft,  and  then  it  becomes 
a  positive  advantage.  In  the  shallower  cases,  it  is  not  of  much 
moment,  as  there  is  no  mouth  so  hard  as  not  to  yield  the  ttjW  or 
TTHTTT  of  an  inch." 

A  counter-die  should  be  soft.  Lead  is  decidedly  the  best  metal  for 
this  purpose ;  tin  may  be  used  if  the  die  is  made  of  zinc.  It  is  desirable, 
if  practicable,  that  the  metal  last  poured  (in  sand  moulding  this  is  the 
counter-die)  should  melt  at  a  lower  temperature  than  the  other.  In 
this  respect  zinc  and  lead  are  admirably  suited — zinc  melting  at  770° 
and  lead  at  600°.  Tin  melting  at  440°  might  be  supposed,  in  this 
respect,  better  than  lead;  but  such  is  not  the  fact,  owing  to  the  ten- 
'  dency  of  tin  and  zinc  to  form  alloys,  while  lead  and  zinc  have  no  such 
affinity. 

In  a  paper  on  metallic  dies,  published  in  the  fourth  volume  of  the 
American  Journal  of  Dental  Science,  Prof.  Austen  gives,  as  the  result 
of  careful  experiment,  the  following  tabular  view  of  the  fusible  alloys 
— zinc  being  introduced  for  the  purpose  of  comparison: — 


Melting 

Contrac- 

Hard- 

Bbittle- 

Point. 

tility. 

ness. 

NESS. 

1.  Zinc 

770° 

•01366 

■018 

5 

2.  Lead,  2  :  tin,  1 

440° 

•006B3 

•050 

3 

3.  Lead,  1 ;  tin,  2 

340° 

■00500 

•040 

3 

4.  Lead,  2  ;  tin,  3 ;  antimony,  1 

420° 

■00483 

•026 

7 

5.  Lead,  5 ;  tin,  6 ;  antimony,  1 

320° 

•00566 

•035 

6 

6.  Lead,  5:  tin,  6;  antimony,  1  ;  bismuth,  8 

800° 

•00266 

•030 

9 

7.  Lead,  1 ;  tin,  1 ;  bismuth,  1     . 

250° 

■00066 

•042 

7 

8.  Lead,  5;  tin,  8;  bismuth,  8     . 

200° 

•00200 

•045 

8 

9.  Lead,  2;  tin,  1 ;  bismuth,  8     . 

200° 

•00133 

•048 

7 

The  last  column  contains  an  approximate  estimate  of  the  relative 
brittleness  of  the  samples  given.  As  in  the  other  columns,  the  low 
numbers  represent  the  metals,  so  far  as  this  property  is  concerned,  most 
desirable.  Those  marked  below  5  are  malleable  metals ;  those  above  5 
are  brittle;  zinc,  marked  5,  separates  these  two  classes,  and  belongs  to 
one  or  the  other,  according  to  the  way  in  which  it  is  managed. 

In  all  cases  of  melting  it  is  a  safe  rule  to  pour  the  metals  at  the 
lowest  temperature  at  which  they  will  flow.  It  is  prudent,  also,  to 
coat  the  metal  on  which  other  metal  is  poured  with  a  mixture  of 
alcohol  and  whiting,  to  prevent  all  chance  of  adhesion.     One  more 


DIES   AND   COUNTER-DIES — SWAGING   PLATES. 


731 


very  important  caution  in  the  melting  of  zinc  and  lead  is  invariably 
to  use  separate  ladles;  for  any  lead  left  from  a  previous  melting  flows 
from  the  ladle  with  the  last  portions  of  the  zinc,  and  being  heavier 
(in  the  proportion  of  11  to  7)  and  more  fluid,  falls  at  once  to  the  bottom 
of  the  matrix,  making  the  alveolar  ridge  more  or  less  of  a  soft  metal, 
thus  totally  desti'oying  its  usefulness. 

The  elastic  vapor  generated  by  the  contact  of  the  water  in  the  sand 
with  the  hot  metal  sometimes  collects  under  or  rises  through  the  metal, 
and  renders  the  casting  more  or  less  imperfect.  This  may  be  prevented  : 
1,  by  drying  the  sand;  2,  by  using  coarse  or  loosely-packed  sand,  and 
avoiding  too  much  moisture ;  3,  by  mixing  the  sand  with  oil  instead 
of  water.  The  slightest  moisture  on  one  metal,  previous  to  the  pouring 
of  another  metal  upon  it,  will  make  the  latter  imperfect. 

In  making  metallic  dies  for  partial  cases,  about  three-fourths  of  the 
crowns  of  the  teeth  should  be  cut  from  the  plaster  model  before  using 
it  for  moulding.  The  plate  can  thus  be  fitted  more  easily  and  perfectly 
than  can  be  done  when  the  teeth  remain  on  the  plaster  model  and  zinc 
die ;  for,  in  the  former  case,  the  plate  need  not  be  cut  to  fit  the  teeth 
until  it  has  been  swaged,  while  in  the  latter  this  must  be  done  first; 
consequently,  in  striking  it  up,  it  will  be  drawn  to  a  greater  or  less 
distance  away  from  them.  There  is  also  danger  of  splitting  the  plate, 
in  swaging  it  into  the  spaces  between  the  teeth,  if  these  are  left  on  the 
metallic  die. 

We  shall  conclude  the  section  on  metallic  dies  by  giving  some  prac- 
tical suggestions  by  Prof.  Austen,  on  the  properties  and  uses  of  the 
metals  and.  alloys  employed  for  this  purpose. 

Many  of  the  properties  of  these  metals,  though  most  interesting,  are 
not  practically  useful  to  the  dentist;  but  there  are  some  points,  for 
which  he  usually  refers  to  his  memorandum-book,  that  should  be 
printed  on  the  page  of  his  memory.  The  following  tables  present  two 
properties  of  certain  metals  in  a  form  convenient  for  memorizing; 
although  not  absolutely  accurate,  they  are  quite  enough  so  for  use  in 
the  dental  laboratory: — 

Okdek  of  Specific  Gravity. 
Lead,         .         .         .         11.5 

Bismuth,        .         ,  .10. 
Cadmium,           .         .  8.5 

Tin,       .         .         .  .75 
Zinc,          ...  7. 

Antimony,    .         .  .6.5 

In  the  fusibility  table,  copper  is  given  to  show  how  unsuited  it  is 
for  laboratory  use.  Eemembering  that  900°  is  red  heat,  the  next  four 
numbers  may  be  easily  memorized.     In  the  specific  gravity  table, 


Order  of 

FUSIBILITT. 

Copper, 

2000° 

Antimony, 

. 

900° 

Zinc,    . 
Lead, 

• 

770° 
600° 

Bismuth, 

500° 

Tin  and  cadmium,     . 

440° 

732  MECHANICS. 

copper  9.  and  iron  8.  are  omitted,  so  as  to  present  the  table  in  a  form 
easily  remembered. 

The  only  pure  metals  suitable  for  a  die  are  zinc  and  tin ;  for  a 
counter-die,  tin  and  lead ;  zinc  makes  the  best  die,  lead  the  best 
counter-die.  Copper  is  too  hard  to  fuse ;  antimony  and  bismuth  are 
too  brittle;  cadmium  is  too  expensive.  All  other  metals  used  in 
swaging  are  alloys. 

Zinc  and  lead  are  valuable  because :  They  are  so  unlike  that  they 
are  not  easily  mistaken  for  each  other;  a  very  common  error  when 
alloys  are  used.  They  have  no  such  disposition  to  alloy  as  zinc  and 
tin  or  tin  and  lead  have.  Zinc  is  so  hard,  one  die  will  suffice  for  many 
cases ;  three  are  sufficient  for  the  most  difficult.  The  brittleness  may 
be  corrected  by  the  size  of  the  die.  Its  shrinkage  is  often  a  decided 
advantage ;  and  in  some  cases,  where  it  makes  the  plate  bind  on  the 
alveolus,  the  contraction  may  be  anticipated  by  coating  these  parts  on 
the  model  with  one  or  two  '■  layers  of  very  thin  plaster.  Zinc,  after 
repeated  use,  becomes  defective ;  hence,  a  supply  of  new  metal  should 
always  be  kept. 

No  metal  equals  lead  as  a  counter-die.  Its  weight  and  softness  are 
in  its  favor  for  this  purpose,  A  counter-die  cannot  be  too  large  or 
heavy  ;  convenience,  of  course,  limits  its  size.  A  difficult  plate  cannot 
be  swaged  with  a  small  counter-die,  unless  the  work  is  nearly  com- 
pleted by  partial  counters,  hammers,  etc.,  before  using  it.  As  regards 
softness,  the  greater  the  disparity  between  die  and  counter,  the  less 
will  be  the  change  in  the  die  by  the  act  of  swaging.  The  plate  is 
forced  by  the  counter  into  the  depressions  of  a  die,  not  so  much  by  its 
hardness,  as  by  its  vis  inertia  under  the  swaging  blows.  The  little  dis- 
parity in  the  hardness  of  the  two  dies  is  one  serious  objection  to  the 
use  of  the  second  class  of  operations.  It  is  a  common  practice  to  use 
several  counters,  and  perhaps  only  one  die.  One  die  may  in  a  few 
cases  suffice ;  two  are  better,  and  often  three ;  but  good  swaging  never 
demands  more  than  one  counter-die,  where  that  is  properly  made. 

With  zinc,  lead,  and  one  fusible  alloy  (lead,  tin  and  bismuth,  equal 
parts),  all  swaging  operations  may  be  completed  when  the  dies  are 
made  by  sand  moulding,  or  by  pouring  zinc  into  the  impression.  But 
since  many  prefer  other  methods  of  making  dies,  it  is  important  to 
understand  the  subject  of  alloys.  Experiment  is  here  the  only  basis 
of  knowledge,  for  no  a  priori  reasoning  could  deduce  the  singular 
changes  caused,  and  new  properties  developed,  by  alloying. 

The  alloy  of  two  brittle  metals  is  always  brittle,  and  a  brittle  metal 
usually  imparts  this  property  to  a  tough  one  nearly  in  proportion  to 
its  percentage.  But  that  two  tough  metals  can  make  a  brittle  alloy  is 
remarkable.     Malleable  copper,  with  half  its  weight  of  brittle  zinc, 


DIES   AND   COUNTER-DIES — SWAGING   PLATES. 


733 


gives  hard  brass,  which,  though  less  tough  than  copper,  is  not  brittle. 
But  malleable  copper,  with  malleable  tin  in  the  same  proportions, 
makes  speculum  metal — the  most  brittle  alloy  known.  A  similar 
instance  is  that  of  lead,  the  softest  of  metals,  which  will,  in  minute 
quantities,  make  gold,  the  most  malleable  of  all  metals,  very  brittle. 

Another  remarkable  property  of  all  alloys  is  fusibility.  Alloys  fuse 
below  the  average  melting  point  of  their  constituents.  Ternary  com- 
pounds exhibit  this  more  strikingly  than  binary.  The  following  table, 
in  illustration  of  this  property,  will  be  found  practically  useful  to  the 
dentist  in  the  selection  of  alloys : — 


Allots 

OF  Bismuth, 

Lead  and  Tin. 

Btsmuth,  500°. 

Lead,  600°. 

Tin, 440° 

Fahrenheit. 

1 

10 

1 

540° 

2 

5 

1 

510° 

3 

2 

1 

440° 

4 

1 

1 

370° 

5 

2 

3 

335° 

6 

1 

2 

340° 

7 

1 

5 

380° 

8 

1 

4 

4 

320° 

9 

1 

2 

2 

290° 

10 

1 

1 

1 

260° 

11 

2 

1 

1 

220° 

It  will  be  noticed  that  two  pounds  of  lead  do  not  make  one  pound 
of  tin  harder  to  melt ;  whilst  a  half  pound  reduces  its  fusion  point 
100°.  Also,  Nos.  6  and  7,  though  containing  more  tin  than  No.  5,  are 
harder  to  melt.  Again,  a  pound  of  bismuth  added  to  alloy  No.  4 
reduces  its  melting  point  110°.  No.  11  and  all  alloys  containing  much 
bismuth  are  brittle.  The  alloys  of  this  table  vary  somewhat  in  hard- 
ness, but  all  are  harder  than  tin. 

The  "  alloying  metals  "  of  the  dental  laboratory  are  copper,  antimony, 
and  bismuth.  Copper  gives  hardness  to  zinc  and  tin,  and  is  sometimes 
combined  with  alloys  of  the  two.  But  the  high  fusion  point  of  copper 
renders  it  less  useful  to  the  dentist  than  the  other  two  metals.  The 
alloy  of  copper,  antimony  and  tin  (Babbit's  metal)  is  perhaps  the  only 
one  of  practical  interest.  Its  advantage  over  zinc,  in  being  less  liable 
to  contract,  is  perhaps  set  off  by  the  tendency  of  most  alloys  to  change 
their  composition  by  frequent  melting;  and  the  danger  of  mixing 
different  alloys,  from  absence  of  those  distinctive  marks,  such  as  sepa- 
rate zinc  and  lead. 

Antimony  is  a  more  valuable  alloying  metal.  It  hardens  tin,  but 
its  chief  use  in  the  laboratory  is  to  harden  lead,  making  type  metal. 
Small  types  composed  of  lead  4,  antimony  1,  are  too  brittle;  and  large 


734  MECHANICS. 

types,  lead  6,  antimony  1,  are  scarcely  fit  for  laboratory  use.  In  the 
proportion  of  9  to  1,  antimony  corrects  the  excessive  contraction  of 
lead,  and  hardens  it ;  yet  leaves  it  tough,  so  as  to  resist  the  blows  of 
swaging.     It  is  suitable  only  for  counter-dies. 

The  very  common  opinion  that  antimony  causes  lead  to  expand  on 
cooling  is  erroneous.  The  alloy  has  a  slight  expansion  at  the  moment 
of  solidification ;  but  after  that,  it  obeys  the  universal  law  of  all  metals, 
and  contracts  as  it  cools.  Actual  contraction  depends  upon  the  ratio 
of  contraction  and  the  fusion  point;  thus,  lead  contracts  more  than 
zinc  because  its  high  ratio  of  contraction  more  than  compensates  its 
lower  fusion  point. 

Another  common  error  is  that  a  zinc  die  poured  very  hot  is  smaller 
than  if  poured  at  its  fusion  point.  Of  course,  contraction  begins  the 
moment  cooling  begins  ;  but  so  long  as  the  metal  is  fluid,  it  necessarily 
fills  the  matrix,  and  contraction  causes  simply  subsidence  of  the  metal. 
No  die  begins  to  leave  the  walls  of  the  matrix  until  it  solidifies  ;  hence, 
the  amount  of  contraction  is  the  same  in  all  cases.  Very  hot  zinc 
copies  minutely  the  sand  surface,  and  thus  has  not  that  bright,  smooth 
appearance  of  cooler  zinc,  which  sets  before  penetrating  the  sand  in- 
terstices ;  but  both  are  equally  good.  Another  difference  is  in  the 
greater  depth  in  the  cavity  on  the  back  of  the  hot-poured  die.  But 
this  is  not  as  objectionable  as  many  think  ;  no  good  mechanic  strikes 
directly  upon  the  die,  but  upon  some  ovoid  or  conical  piece  of  metal 
covering  this  cavity  in  the  back. 

Bismuth  is  perhaps  the  most  valuable,  to  the  dentist,  of  the  three 
alloying  metals.  Antimony  gives  hardness,  but  not  much  fusibility  ; 
bismuth  gi^^es  fusibility,  but  no  great  hardness.  The  table  above 
given  shows  the  marked  effect  of  this  metal.  It  is  seldom  used  as  a 
binary  alloy,  because  its  fluxing  qualities  are  more  fully  brought  out 
in  ternary  combination ;  also  because  of  its  expensiveness,  and  its 
tendency  to  impart  brittleness.  Type  metal  is  rendered  more  fusible 
by  the  addition  of  .05  per  cent,  of  bismuth. 

Bismuth,  antimony  and  zinc  are  readily  distinguished — bismuth  by 
its  great  weight  and  characteristic  pinkish  color ;  antimony  by  its 
peculiar  crystallization  and  its  excessive  brittleness.  But  the  alloys 
of  these  metals  with  tin  and  lead  have  such  a  general  resemblance, 
that  they  must,  with  much  care  and  system,  be  kept  apart  in  properly 
labeled  boxes  ;  otherwise,  if  more  than  one  alloy  is  used,  the  annoy- 
ance caused  by  using  one  for  another  will  more  than  offset  their  utility; 
in  fact,  such  negligence  defeats  their  usefulness. 

Dr.  L.  P.  Haskell  claims  that  the  following  formula  for  preparing 
the  Babbit  metal  is  superior  to  all  others  for  use  as  a  die  :  Tin,  8 
parts ;  copper,  1  part ;  antimony,  2  parts.     For  a  counter-die  for  such 


DIES   AND   COUNTER-DIES — SWAGING   PLATES.  735 

a  die,  he  recommends :  Lead,  7  parts  ;  tin,  1  part.  He  claims  that 
such  a  Babbit  alloy  for  the  die  cannot  be  excelled. 

Dr.  C.  J.  Essig  recommends  zinc  for  a  counter-die  for  swaging  a 
plate  of  platinum-gold  or  iridium-platinum  ;  and  also  that  such  a 
counter-die  is  of  especial  service  in  partial  cases  where  a  number  of 
teeth  remain.  For  difficult  swaging  he  recommends  three  sets  of  dies 
and  counter-dies,  the  most  imperfect  of  the  dies  being  furnished  with 
a  lead  counter-die,  to  be  first  used,  and  the  next  in  quality  to  be  used 
with  a  zinc  counter-die,  and  the  nearest  perfect  of  all  with  a  lead 
counter-die  as  a  finishing  die. 

The  following  mechanical  instruments  will  constitute  a  student's 
college  outfit,  exclusive  of  such  .heavy  apparatus  as  vulcanizers,  lathes, 
rollers,  etc. :  1  saw  frame  and  12  saws;  2  rubber  scrapers  ;  1  hammer 
and  handle;  1  Scotch  stone;  1  plaster  knife  ;  1  wax  knife,  double  end; 
1  plate  brush  ;  1  plaster  spatula ;  1  pair  calipers ;  1  rubber  file,  double 
end;  1  flask  and  wrench  ;  2  pliers  (round  and  flat  nose) ;  1  borax  glass; 
1  graver;  1  pair  solder  tweezers;  1  blowpipe;  1  plate  file;  1  pair 
plate  shears  (best)  ;  1  horn  mallet  for  swaging ;  1  punch  forcep. 

SWAGING. 

A  die  and  counter-die  having  been  obtained,  a  piece  of  tin  foil  or 
sheet  lead  is  adapted  to  the  former,  and  the  dimensions  of  the  plate 
marked  upon  it.  Paper  is  sometimes  used  for  this  purpose,  but  is  not 
so  good  as  thin  sheet  lead  or  heavy  tin  foil.  The  pattern  thus  made  is 
cut  out,  flattened  and  laid  upon  the  gold  plate,  and  its  outline  marked 
upon  it.  The  plate  should  be  cut  a  little  too  large,  to  allow  for  trim- 
ming and  any  accidental  slipping  upon  the  die.  In  partial  cases  the 
pattern  should  be  carried  partly,  or  fully,  over  the  excised  teeth,  and 
no  attempt  made  to  fit  it  accurately 
around  the  necks  of  the  teeth  until  the  ^^^-  ^^9. 

swaging  is  nearly  or  quite  completed. 
With  a  pair  of  strong  shears  the  por- 
tion of  plate  thus  marked  is  cut  out. 
Fig.  539  represents  a  pair  of  shears, 
with  long  and  conveniently-shaped 
handles.  The  blades  of  some  shears  are  curved  laterally;  but  this 
form  is  not  desirable.  A  fine  watch-spring  saw.  Fig.  419,  should  be 
used  for  curves  which  the  straight  shears  will  not  cut ;  for  very  short 
curves,  around  teeth  for  instance,  a  pair  of  cutting  forceps,  shaped  as 
in  Fig.  542,  will  be  found  useful. 

Figs.  540  and  541  represent  nippers  for  cutting  out  plate. 

Cutting  plates  to  shape  before  swaging  is,  however,  not  only  unne- 
cessary, but  is  in  many  cases  a  positive  disadvantage.     Swaging  the 


736 


MECHANICS. 


square  plate  is  greatly  preferable  in  the  lower  jaw,  since  it  permits 
working  from  the  centre  outward.  And  in  both  upper  and  lower 
plates,  the  two  triangular  pieces  outside  the  ridge  help  to  prevent 
plaiting,  or  doubling  of  the  plate.     Purchased  j^lates  are  ordered  to 


Fig.  540. 


pattern,  on  the  score  of  economy  ;  but  the  difference  is  trifling,  since 
good  plate  scrap  has  nearly  the  same  value  as  the  original  plate,  and 
every  careful  operator  separates  his  plate  scrap  from  his  solder  scrap 


and  filings.  After  swaging  is  nearly  completed,  with  partial  counters 
and  hammers,  the  square  plate  may  be  quickly  trimmed  to  shape  by 
means  of  a  jeweler's  saw. 

Fig.  542. 


The  plate  must  next  be  well  annealed,  and  partially  fitted  by  wooden, 
horn,  or  leaden  hammers,  to  that  part  of  the  die  inside  the  ridge. 
There  is  no  better  hammer  for  this  purpose  than  lead  ;  but,  of  course, 
the  plate  must  be  thoroughly  cleansed  of  all  trace  of  the  lead  before 


DIES   AND   COUXTER-DIES — SWAGING   PLATES. 


737 


annealing.  The  swaging  is  continued  by  the  use  of  partial  counter- 
dies  ;  these  are  made  by  placing  a  rim  of  clay  or  putty  around  the 
ridge  and  back  part  of  the  metallic  die,  and  pouring  on  it  fusible 
metal.  In  this  way,  the  plate  should  be  perfectly  fitted  so  far  as  the 
ridge.  Then,  clamping  the  plate  between  the  die  and  the  partial 
counter,  the  edge  is  to  be  gradually  carried  over  the  top  and  outside  of 
the  ridge  with  hammers  and  small  wooden  or  ivory  stakes.  The  plate 
may  be  clamped  in  a  vise,  or  by  means  of  a  string  passing  over  the  die 
and  under  the  foot ;  but  a  much  more  convenient  method  is  found  in 
the  use  of  Dr.  T.  H.  Burras's  clamps.  Fig.  543.  Of  the  two  forms  here 
given,  the  sliding  arm  (No.  2)  is  preferable  to  the  long  screw  (No.  1). 
The  application  of  the  clamp  is  so  plainly  shown  in  No.  1,  that  any 
description  is  unnecessary. 

Fig.  543. 

No.  1.  No.  2. 


It  is  the  practice  of  some  to  cut  out  V-shaped  pieces  from  the  front 
or  back  part  of  the  plate,  to  prevent  the  plaiting  of  the  metal.  This 
is  very  bad  practice  and  is  never  called  for,  if  due  care  is  used  in 
swaging  and  the  metal  is  of  proper  fineness.  To  avoid  plaits  or  folds, 
anneal  often,  and  in  deep  arches  carry  the  plate  down  very  gradually  ; 
also  take  care  in  such  cases  that  the  plate  be  thick,  to  allow  for  stretch- 
ing or  drawing.  In  swaging  over  the  ridge,  it  is  a  very  common  mis- 
take to  hammer  down  the  outside  before  fully  striking  up  (with  ham- 
mer and  stakes)  the  parts  nearest  the  partial  counter-die.  Always 
make  it  a  rule,  in  carrying  the  plate  over  the  ridge,  to  swage  from  the 

47 


738  MECHANICS. 

centi'e  outward,  carrying  the  plate  "  home"  as  you  proceed.  In  deep 
arches,  irregular  alveolar  ridges,  and  in  prominent  lower  ridges, 
swaging  must  be  done  slowly  and  with  great  care. 

All  forms  of  bending  forceps  are  worse  than  useless.  They  bruise 
the  plate,  as  will  any  steel  or  hard  metal  instruments.  There  is  no 
shape  of  arch  or  of  plate  which,  by  the  above  simple  process,  cannot  be 
perfectly  fitted  with  a  twenty-carat  plate.  The  elaborate  forms  of  a 
window  cornice  or  a  jelly  mould  should  teach  any  dentist  how  poor  a 
mechanic  he  is  when  he  complains  of  the  difficulty  of  swaging  so  highly 
malleable  a  metal  as  gold  into  and  over  the  irregularities  of  any  mouth. 
And  when,  to  save  his  skill,  he  pleads  want  of  time,  he  exposes  a 
graver  deficiency — dishonesty. 

The  fitting  of  the  plate  being  thus  almost  completed  by  hammers  and 
partial  counters,  it  should  be  trimmed  to  its  exact  shape,  and  then 
placed  between  a  fresh  die  and  the  full  counter-die,  and  carried  "home" 
by  several  firm  blows  of  the  hammer,  given  directly  over  the  centre  of 
the  die.  The  hammer  should  not  weigh  more  than  three  pounds,  with 
a  handle  about  a  foot  long.  It  is  a  great  mistake  to  use  a  very  heavy 
or  a  very  long-handled  hammer.  The  striking  block  may  be  an  anvil, 
or  a  large  wooden  block  set  in  sand  or  on  a  cushion,  and  the  base 
of  the  counter-die  must  rest  steadily  upon  it.  It  greatly  facilitates 
swaging,  and  makes  one  independent  of  any  striking  block,  to  have  a 
very  thick  and  heavy  lead  counter.  As  there  is  always  a  hollow  in 
the  back  of  a  zinc  die,  a  conical  piece  of  iron,  steel  or  other  hard  metal, 
should  be  placed  upon  it  to  centralize  the  blow  of  the  hammer.  An 
egg  shell,  filled  with  plaster,  is  useful  for  making,  at  the  time  of 
moulding  the  die,  several  zinc  blocks  for  this  purpose.  To  a  disregard 
of  these  precautions  is  due  much  of  the  difficulty,  so  often  complained 
of,  in  the  tilting  or  rocking  of  plates  and  dies. 

Throughout  the  entire  process  of  swaging,  the  plate  must  be  fre- 
quently annealed.  It  may  be  suddenly  cooled  after  all  except  the 
final  annealing;  when  the  cooling  must  be  very  gradual,  so  as  to  avoid 
warping  or  springing.  The  malleability  of  gold  plate  will  permit  a 
great  deal  of  swaging  without  annealing ;  yet  the  neglect  of  this  simple 
operation  is  unsafe.  One  broken  or  cracked  plate  gives  more  trouble 
than  the  annealing  of  a  dozen.  The  plate,  after  final  swaging,  must 
be  taken  from  the  counter  very  carefully,  to  avoid  change  of  shape. 
Thin  paper  in  the  counter-die  makes  removal  easier;  it  is  also  easier 
when  only  one  counter  is  used.  Too  much  swaging  gives  the  plate  a 
loose  fit. 

When  block  tin,  lead  or  fusible  metal  dies  or  counter-dies  are  used 
in  swaging  the  plate,  any  portion  of  these  metals  which  may  adhere  to 
it  should  be  removed  before  annealing,  as  their  fusion  upon  its  surface 


DIES   AND   COUNTER-DIES — SWAGING   PLATES.  739 

alloys  theiu  with  the  gold,  and  will  render  it  brittle  and  impair  its 
ductility,  or  else  eat  holes  in  the  plate  at  the  spot  where  the  particles 
of  baser  metal  form  an  alloy,  fusible  at  the  annealing  heat.  This  is 
done  either  by  mechanical  or  chemical  means.  If  acid  is  used,  it 
should  be  dilute  nitric,  since  sulphuric  will  not  dissolve  lead ;  but  be 
very  careful  that  the  nitric  acid  contains  no  hydrochloric,  else  the 
plate  will  be  acted  upon.  The  liability  of  the  tin  or  lead  to  adhere  to 
the  gold  may  be  measurably  prevented  by  oiling  the  plate  before  it  is 
struck  up. 

Figs.  544  and  545  represent  the  general  forms  of  upper  and  lower 
plates  after  the  swaging  process  is  completed.  In  the  upper  plate  is 
represented  the  proper  size  and  position  of  a  vacuum  cavity,  whenever 
it  may  be  thought  proper  to  use  one.  The  question  of  the  cavity  will 
be  elsewhere  discussed. 

■  If  on  trial  of  the  plate  in  the  mouth  it  does  not  fit  properly,  the 
operator  must  proceed  to  ascertain  the  cause  of  failure.     And,  first, 

Fig.  544.  Fig.  545. 


whether  it  is  temporary  or  permanent.  .  A  plate  which  falls  because  it 
rocks  over  a  hard  palate  will  never  improve;  if  because  it  fails  to  go 
fully  into  the  palate,  it  may  daily  improve,  and  ultimately  adhere  with 
great  firmness.  Most  plates  made  soon  after  extraction  fit  badly  until 
the  alveolar  prominences  are  pressed  down  by  wear.  Some  very  hard 
mouths  will  not  retain  the  plate  until  it  has  been  worn  for  a  time, 
especially  if  the  mouth  is  very  flat.  Deep  arches,  or  uniformly  soft 
mouths,  should  retain  the  plate  firmly  from  the  first. 

The  use  of  pliers,  except  for  bending  the  edge  into  some  alveolar 
undercut,  is  an  evidence  of  bad  work.  The  back  margin  of  upper 
plates,  so  often  adjusted  in  this  way,  is  much  better  fitted  by  scraping 
the  model  at  the  place  where  the  plate  should  bind  ;  this  should  be 
done  to  a  depth  proportioned  to  the  softness  of  the  membrane. 

Much  judgment  is  demanded  in  deciding  upon  the  necessity  for  a 
new  plate.     The  impression  may  have  been  badly  taken,  or  with  a 


740  MECHANICS. 

material  not  adapted  to  the  mouth.  The  dies  may  have  been  carelessly 
made,  or  the  swaging  imperfectly  done.  Trial  of  the  plate  is  essential 
to  ascertain  all  these  points,  that  the  articulation,  soldering,  etc.,  may 
not  be  so  much  additional  labor  in  vain. 

The  different  forms  of  plates,  full  and  partial,  will  hereafter  be  con- 
sidered. They  are  retained  in  the  mouth  by  clasps  or  stays;  by  the 
adhesion  of  contact  or  by  the  vacuum  cavity,  the  retaining  force  being 
atmospheric  pressure;  by  the  elastic  spring  of  the  wings  of  the  plate ; 
by  spiral  springs.  These  will  be  taken  up  in  a  subsequent  chapter, 
and  their  relative  merits  discussed.  We  pass  now  to  the  step  which, 
in  swaged  work,  comes  next  in  order  to  the  fitting  of  the  plate — the 
means  for  securing  its  exact  relation  to  the  natural  teeth,  or,  in  double 
sets,  its  relation  to  the  opposing  plate.  These  processes  come  under 
the  technical  head  of  Articulation. 


CHAPTER  X. 

ARTICULATION. 


THE  term  Articulation,  as  used  in  Dental  Mechanics,  comprehends 
several  distinct  operations,  implied  in  the  use  of  the  terms  (1) 
Articulating  impressions,  (2)  Articulating  plates,  (3)  Articulating 
models. 

In  many  partial  sets  it  is  best,  after  fitting  the  swaged  plate  to  the 
mouth,  to  take  a  wax  impression  with  the  plate  in  situ.  This  gives  the 
precise  relation  of  the  plate  to  the  adjacent  teeth  ;  and  upon  applica- 
tion of  a  model  of  the  lower  jaw,  it  gives  the  relation  of  the  plate  to 
the  antagonist  teeth.  This  and  all  other  impressions  of  the  relation 
of  plates  to  the  teeth,  or  to  each  other,  in  the  mouth,  we  call  articu- 
lating impressions. 

A  base  plate  becomes  an  articulating  plate  when  the  articulating  rim 
is  attached  which  has  the  impress  of  its  opposite  rim  or  teeth.  In 
swaged  work,  it  is  the  gold  plate  itself;  in  plastic  work,  it  is  some 
temporary  plate  of  tin,  lead  or  gutta-percha. 

The  articulating  models  make  up  what  is  technically  called  an 
"  Articulator,"  of  which  there  are  many  forms ;  all,  however,  compre- 
hended under  three  varieties,  (a)  Those  made  wholly  of  plaster 
poured  into  the  articulating  plates.  {h)  Those  in  which  the  model 
portion  is  poured  into  the  articulating  plates ;  but  the  back,  or  hinged 
portion,  is  metallic,     (c)  Those  in  which  the  original  models  are  set 


ARTICULATION.  741 

into  the  articulating  plates,  and  some  complicated  metallic  articulator 
adjusted  to  them.  Each  of  these  classes  have  special  advantages 
adapting  them  to  various  exigencies  of  practice. 

Whenever,  in  partial  cases,  there  are  three  points  of  contact  suffi- 
ciently apart  to  give  firm  antagonism,  Prof.  Austen's  plan  is  to  take  an 
impression  of  the  lower  teeth ;  this  gives  a  model  which  antagonizes 
perfectl}^  with  the  upper  model,  and  makes  the  articulator  without 
further  trouble.  This  plan,  specially  applicable  to  vulcanite  work,  is 
adapted  to  swaged  work  by  taking  the  articulating  impression  de- 
scribed in  the  second  paragraph  of  this  chapter.  Such  articulators 
require  no  backward  extension  or  hinge,  because  the  articulation  is 
determined  by  the  articulating  cusps  of  the  teeth. 

In  partial  cases,  where  there  are  only  one  or  two  points  of  antago- 
nism, and  where,  consequently,  the  opposition  of  the  corresponding 
teeth  would  be  uncertain,  the  necessity  exists  for  some  third  point  of 
support.  This  is  best  given  by  a  backward  extension  of  the  model,  so 
as  to  permit  motion  of  the  two  halves  of  the  articulator,  somewhat 
resembling  that  of  the  natural  jaws  ;  though  many  partial  cases  do  not 
require  such  an  extension.  In  putting  this  wax  rim  on  the  plate,  it  is 
better  in  all  cases  to  trim  it,  as  is  done  for  full  upper  sets ;  but  where 
there  are  remaining  teeth,  the  antagonism  of  these  determines  the 
proper  closure  of  the  mouth,  and  this  is  not  essential.  The  plate  and 
adherent  wax  are  placed  in  the  mouth ;  the  patient  is  then  requested 
to  close  the  mouth  naturally,  imbedding  the  teeth  of  the  lower  jaw  in 
the  wax.  While  the  mouth  is  thus  closed,  the  wax  on  the  outside  of 
the  teeth  and  alveolar  ridge  is  pressed  closely  against  them. 

This  done,  the  plate  and  wax  impression  are  carefully  removed, 
filled  with  plaster,  and  placed  on  a  piece  of  wet  paper,  with  the  wax 
downward.  The  upper  side  of  the  plate  is  then  oiled.  As  the  plaster 
stiffens,  it  may  be  applied  until  it  is  raised  half  an  inch  above  the  plate, 
and  extended  back  of  it  on  the  paper  an  inch  and  a  half  or  two  inches. 
As  soon  as  the  plaster  has  set,  its  edges  may  be  neatly  trimmed  ;  and  at 
the  back  of  the  surface  next  the  paper  a  deep  transverse  or  T-shaped 
groove  should  be  cut,  to  serve  as  a  mould  for  the  formation  of  a  cor- 
responding ridge  on  the  half  model  with  which  this  is  to  antagonize. 
This  grooved  surface  must  be  coated  with  oil,  or  soap  water,  or  varnish, 
or  covered  with  a  layer  of  tin  foil  or  thin  paper.  Then  partly  fill  the 
space  inclosed  by  the  wax  rim  with  clay,  putty,  or  Avet  paper,  and 
pour  on  plaster  to  form  the  other  half  model.  In  running  plaster  into 
the  wax  impressions  of  the  teeth,  be  very  careful  to  avoid  air  bubbles 
and  flaws,  and  do  not  oil  the  wax.  After  the  plaster  has  set,  it  may 
be  trimmed  as  before  directed. 

Another  and  often  more  convenient  method  is  to  take  a  strip  of  sheet 


742 


MECHANICS. 


lead  one  and  a  half  inches  wide,  and  bend  it  to  the  required  outline  of 
the  articulator.  Pour  this  partly  full  of  plaster,  and  set  the  plate, 
previously  filled  -with  plaster,  upon  it.  Cut  the  grooves  as  before  de- 
scribed, and  pour  the  other  half  of  the  articulator.  The  lead  rim 
saves  much  manipulation  and  trimming,  which,  in  the  other  case,  the 
plaster  requires.  When  the  half  last  made  has  become  sufficiently 
hardened,  the  two  pieces  may  be  separated,  after  softening  the  wax  in 
warm  water,  and  the  wax  carefully  removed.  The  model  is  then  var- 
nished, for  greater  comfort  in  handling,  and  when  put  together  may 
present  an  appearance  exhibited  in  Fig.  546. 

The  artist  has  failed  in  this,  and  in  other  designs  of  the  plaster 
articulator,  to  represent  the  tapering  shape  which  it  is  best  to  give  to 
the  back  half  of  the  models,  for  greater  convenience  of  holding  them 
while  adapting  the  teeth.  The  fault  of  many  plaster  articulators  is 
that  they  are  too  large  and  clumsily  shaped.     In  any  given  case,  the 

Fig.  546. 


proper  distance  of  the  groove  or  hinge  is  the  distance  from  the  patient's 
external  auditory  meatus  to  the  line  of  the  front  teeth  or  alveolar  ridge. 
The  width  and  thickness  of  the  articulator  must  vary  with  the  size  or 
depth  of  the  mouth,  avoiding  any  excess  of  plaster  not  necessary  to 
give  requisite  strength. 

For  a  full  upper  set,  or  where  two  or  more  remaining  molars  have 
no  antagonism,  it  is  a  very  common  practice  to  place  on  the  plate  a 
roll  of  wax  sufficiently  large  to  receive  the  imprint  of  the  loAver  teeth, 
and  to  prevent  these  from  closing  too  far  by  the  insertion  of  a  piece 
of  wood  buried  in  the  wax,  and  projecting  at  the  median  line.  The 
closure  is  better  arrested  by  two  lumps  of  sealing  wax  attached  oppo- 
site the  bicuspids,  and  trimmed  to  the  required  length  before  putting 
on  the  wax.  But  the  articulation  ought  to  determine  other  points 
besides  the  single  one  of  space.  Hence  the  antagonizing  plate  should 
be  made  by  adjusting  a  rim  of  wax  corresponding  in  width  to  the 


AETICULATION. 


743 


length  proposed  for  the  artificial  teeth,  and  trimming  it  until  all  the 
teeth  in  the  lower  jaw  touch  it  at  the  same  instant.  Instead  of  wax,  a 
rim  of  gutta-percha  may  be  used  to  represent  the  required  length  and 
external  fullness  of  the  teeth.  When  this  is  satisfactorily  adjusted,  a 
small  rim  of  soft  wax  is  placed  upon  the  wax  or  gutta-percha,  and  the 
mouth  closed  as  naturally  as  possible  until  the  teeth  touch  the  latter- 
The  gutta-percha  can  be  readily  trimmed  with  a  sharp  knife.  Rims 
thus  shaped  give  opportunity  to  ascertain,  by  the  effect  on  the  expres- 
sion of  the  lips,  etc.,  exactly  what  length  and  fullness  of  tooth  suits  the 
particular  case.  Gutta-percha  is  better  than  wax  in  arresting  the 
closure  of  the  teeth,  and  is  decidedly  best  for  the  temporary  articula- 
ting plates  of  plastic  work ;  but  the  latter  is  more  easily  attached  to  a 
gold  plate,  and  is  more  easily  trimmed.  By  making  the  wax  cold,  or 
by  imbedding  a  small  block  of  wood  opposite  the  bicuspids  on  each 
side,  with  the  grain  of  the  wood  running  transversely,  for  easy  trim- 
ming, the  wax  rim  offers  a  firm  resistance. 

There  is  a  tendency  on  the  part  of  the  patient  to  close  the  mouth  to 
one  side,  and  too  far  forward ;  it  is  impossible  to  close  it  behind  the 
natui'al  articulation.  The  simplest  method  for  regulating  this  is  to  keep 
the  body  erect  and  throw  the  head  backward,  so  as  to  make  as  tense 
as  possible  the  throat  muscles,  which  thus  act  as  a  bridle,  and  almost 
compel  a  correct  closure  of  the  mouth.  It  may  also  be  done  by  careful 
observation  of  repeated  closures  made 
by  the  patient  while  sitting  in  an  erect 
natural  position.  The  operator  must 
avoid  impressing  upon  his  patient  the 
necessity  for  an  easy  natural  closure ; 
such  directions  invariably  defeat  their 
object.  Of  course,  these  trials  are  to 
be  made  before  attaching  the  soft  wax 
which  receives  the  impress  upon  the 
final  closure.  A  vertical  median  line, 
traced  on  the  wax,  is  of  service  in 
observing  the  articulation,  and  in  the  subsequent  adjustment  of  the 
artificial  teeth.  Fig.  547  represents  such  a  rim  with  its  original  full- 
ness cut  away. 

For  a  double  set  of  artificial  teeth,  the  following  method  of  articu- 
lation is  often  adopted.  After  having  accurately  fitted  both  plates,  a 
rim  of  soft  beeswax  is  placed  between  them,  about  an  inch  and  a 
quarter  in  width.  A  piece  of  wood,  exactly  corresponding  in  width  to 
the  proposed  length  of  the  upper  and  lower  central  incisors,  is  passed 
through  the  wax  between  the  plates  at  the  median  line  ;  or,  still  better, 
one  piece  on  each  side  between  the  bicuspid  part  of  the  plates.     The 


Fig.  547. 


741 


MECHANICS. 


whole  is  now  placed  in  the  mouth,  and  each  plate  accurately  adjusted 
to  the  alveolar  border.  The  patient  is  then  directed  to  close  the  mouth 
until  the  plates  are  brought  in  contact  with  the  edges  of  the  interposed 
piece  of  wood.  This  done,  the  plate,  wax  and  wood  are  together 
removed  from  the  mouth. 

But  a  far  better  method  consists  in  placing  a  rim  of  wax  or  gutta- 
percha on  each  plate,  giving  the  length,  outline,  and  fullness  respect- 
ively designed  for  the  teeth  of  each  jaw.  The  two  plates  are  put  in 
the  mouth,  and  the  jaws  are  carefully  closed  ;  if  the  rims  of  wax  touch 
at  any  one  point  sooner  than  another,  the  plates  are  removed  and  the 
wax  trimmed  ;  this  operation  is  repeated  until  the  two  rims  of  wax 
meet  all  the  way  round  at  the  same  instant,  and  give  the  pi'oper  con- 
tour to  the  cheeks  and  lips.  The  median  line  is  then  marked,  and  the 
final  closure  of  the  mouth  made  with  the  utmost  care,  so  that  there 

Fig.  548. 


shall  be  no  lateral  or  forward  deviation.  The  exact  position  being 
secured,  the  lower  jaw  is  to  be  held  with  the  left  hand,  while,  with  the 
right,  some  six  or  eight  oblique  indentations  are  made  with  a  wax  knife 
across  the  line  of  contact  between  the  two  rims.  Some  fasten  them 
together  by  a  warm  wax  knife,  or  by  pins,  or  by  small  slips  of  brass 
plate  warmed  and  forced  into  the  wax.  The  pieces  are  removed  jointly 
or  separately  from  the  mouth  ;  if  separately,  they  can,  by  the  aid  of 
these  marks,  be  accurately  readjusted. 

From  these  articulating  plates  a  plaster  articulator  is  made  substan- 
tially in  the  manner  described  for  a  partial  case.  The  lead  rim  for 
shaping  the  models  will  often  have  to  be  two  inches  broad.  If  the 
precaution  is  taken  to  fill  the  space  within  the  wax  rims  and  between 
the  plates  with  paper  pulp,  it  is  not  material  which  half  is  filled  first. 
Usually  the  lower-jaw  model  will  be  thickest,  and  in  this,  made  first, 


ARTICULATION. 


745 


Fig.  549. 


it  is  best  to  cut  the  grooves.  Fig.  548  represents  a  plaster  articulator 
with  the  plates  removed,  in  which  figure,  from  neglect  of  this  point, 
the  thin  upper  half  is  much  weakened  by  the  V-shaped  cut. 

Partly  to  save  plaster, 
but  chiefly  to  permit  mod- 
ification of  the  articula- 
tion, where  inaccuracy  is 
suspected,  quite  a  number 
of  metallic  articulators 
have  been  recommended. 
One  of  the  first  contrived, 
for  this  purpose  was  by 
Dr.  Thomas  Evans,  of 
Paris,  and  made  of  heavy 
brass  wire. 

Fig.  549  represents  a 
very  convenient  form  of 
metallic  articulator.  But 
in  using  this,  and  every 
similar  contrivance,  the  operator  should  remember  that  facility  o± 
changing  the  articulation,  after  the  guiding  wax  rims  are  removed,  is 
a  very  questionable  advantage.  It  tempts  to  carelessness  in  articu- 
lating. Moreover,  if  the  width  of  space,  or  other  relation  of  the  parts, 
is  such  as  leads  to  suspicion  of  inaccuracy,  any  change  of  articulation 
is,  at  best,  a  sort  of  random  guesswork.  The  most  certain  correction 
of  surmised  error  is,  undoubtedly,  to  take  the  articulation  anew. 
Hence  our  preference  is  for  the  old-fashioned  plaster  articulator,  with 
its  unaccommodating  fixedness,  that  neither  offers  a  premium  on  care- 
lessness, nor  puts  the  careful  workman  at  the  mercy  of  some  loose  joint 
or  screw. 

There  is  another  class  of  articulators  more  complicated  than  the 
above,  which  are  very  useful  in  those  cases  where  the  original  models 
are  used,  instead  of  special  models  cast  in  the  articulating  plates. 
Fig.  550  represents  an  articulator  devised  by  Dr.  J.  B.  McPherson, 
the  valuable  feature  of  which  is  the  clamping  fixture  for  holding  the 
plaster  model.  The  danger  of  breaking  frail  models  in  removing 
them  from  the  articulator  is  overcome,  as  they  can  be  removed  by 
simply  loosening  the  clamp.  It  has  also  a  lateral  movement  resemb- 
ling that  of  the  jaw. 

Fig.  551  represents  Dr.  Genese's  articulator,  with  set  or  lock  pin, 
and  interchangeable  model  holders.  The  following  directions  are 
given  for  using  this  articulator  :  Detach  the  model  holder,  leaving  the 
centre  screw  in ;  paint  with  non-adhesive,  and  arrange  on  a  board  with 


746 


MECHAJSriCS. 


the  tube  pointing  away  from  the  operator ;  after  filling  the  impression, 

cover  the  holder  with  plaster  to  the  hilt  and  reverse,  the  tray  upper- 
most. Let  the  centre  of  the  impression  be  in  a  line  with  the  tube  at 
the  back,  making  the  model  slightly  higher  in  the  back  than  ordinary 


Fig.  550. 


Fig.  551. 


ARTICULATION.  747 

models.  When  set,  remove  the  centre  screw  and  draw  the  holder  out, 
wash  in  warm  water,  and  it  is  ready  for  use  again.  The  models  can 
be  trimmed  and  adjusted  immediately  they  are  hard.  The  entire  in- 
strument is  never  soiled  Avith  plaster. 

To  secure  a  hite  for  future  reference. — This  articulator,  as  it  takes  the 
bearings  of  the  entire  surface  of  both  upper  and  lower  models,  without 
injury  to  them,  and  only  a  small  quantity  of  plaster  being  used,  very 
little  shrinkage  occurs,  and  the  bite  can  always  be  replaced  on  the 
articulator  without  the  difference  of  toVo  part  of  an  inch. 

To  arrange  a  hite  for  reference. — Paint  the  models  with  non-adhesive; 
mix  some  plaster  and  pour  in  tissue  paper,  and  place  between  the 
models  that  are  perfectly  articulated  previously ;  gently  close  the  articu- 
lator until  the  pin  enters  its  centre  and  allow  it  to  harden;  as  soon  as 
it  is  set,  trim  up,  and  it  is  then  ready  for  any  future  work.  Any  over- 
lapping edge  or  slender  tooth  may  have  a  little  wax  or  soft  paper 
placed  on  it,  to  prevent  the  plaster  binding  too  tight. 

The  subject  of  articulation  cannot  be  dismissed  without  a  few  words 
upon  the  great  importance  of  extreme  accuracy  in  all  its  details.  It 
is  a  very  remarkable  fact  that  some  of  the  most  painstaking  dental 
mechanicians  practice  methods  of  articulating  in  which  there  can  be 
no  certainty,  and  for  constant  errors  in  which  the  emery  wheel  is  re- 
sorted to,  in  order  to  save  them  the  mortification  of  making  their  work 
anew.  In  fact,  there  is  no  better  evidence  of  the  guesswork  character 
of  an  immense  number  of  articulations  than  the  habitual  attempts  at 
correction  by  the  equally  guesswork  shifting  of  movable  articulators. 
We  assert,  without  hesitation,  that  aisty  articulation — whether  with 
gold  plate  or  with  the  temporary  plates  of  vulcanite  and  other  forms 
of  plastic  work — can  be  taken  in  such  manner  as  not  to  require  the 
slightest  change  in  the  relation  of  the  articulating  models.  We  shall 
not  insult  the  profession  by  attempting  to  prove  that,  if  it  can  be  done, 
it  should  be  done.  Next  in  importance  to  accuracy  of  the  impression 
is  correctness  of  articulation.  Defects  in  either  are  damaging  to  one's 
reputation.  But  there  is  this  difference :  that  in  the  former  the  error 
may  often  be  detected  on  trial  of  the  plate,  while  in  the  latter  case  the 
finished  work  alone  reveals  the  failure. 

Defective  articulation  is  a  prolific  source  of  the  disgraceful  short- 
coming of  Vulcanite  Dentistry.  By  these  terms  we  specialize  that 
art  and  its  accompanying  science,  which  begins  with  Hard  Rubber 
and  ends  with  a  Vulcanizer;  which  knows  nothing  of  the  uses  of  gold 
save  as  a  circulating  medium,  recognizing  no  quality  in  a  dental  mate- 
rial so  highly  as  its  cheapness,  no  merit  in  a  process  so  valuable  as  its 
rapidity.  So  long  as  such  principles  rule  in  the  dental  laboratory, 
carelessness  in  articulation  is  of  little  consequence.     But  older  practi- 


748  MECHANICS. 

tioners,  who  are  accustomed  to  handle  the  royal  metal  with  a  care 
worthy  of  its  high  character,  will  fully  appreciate  the  great  importance 
of  a  rigorously  exact  articulation. 


CHAPTER  XI. 

PRINCIPLES   AND   APPLIANCES   OF   SOLDERING. 

SOLDERING  is  the  union  of  two  metallic  surfaces ;  either  by  slightly 
fusing  the  surfaces  themselves  (technically  termed  sweating,  or 
autogenous  soldering),  as  in  the  union  of  a  plate  of  silver  to  a  block 
of  copper,  preparatory  to  rolling  it  into  Sheffield  plate;  or  by  the  fusion 
of  an  alloy  which  melts  more  readily  than  the  metals  to  be  soldered. 

The  conditions  of  successful  soldering,  as  given  by  Prof  Austen, 
are :  1.  A  freely  flowing  solder.  2.  Absence  of  oxide  from  the  surface 
over  which  the  solder  is  to  flow.  3.  Proper  amount  and  direction  ot 
heat  in  flowing  the  solder.  The  first  condition  requires  good  solder; 
of  this  we  have  elsewhere  spoken.  The  second  calls  for  the  use  of 
borax,  the  specific  action  of  which,  as  a  flux,  is — first,  the  removal  of 
existing  oxide  by  virtue  of  its  powerful  affinity  for  it ;  secondly,  the 
prevention  of  further  oxidation  by  the  exclusion  of  the  oxygen  of  the 
air.  The  third  condition  demands  a  skillful  management  of  the  blow- 
pipe flame;  this  is  the  principal  difficulty  with  most  beginners,  and, 
indeed,  with  not  a  few  old  practitioners. 

The  borax  should  be  used  in  the  lump,  and  rubbed  with  pure  (dis- 
tilled or  rain)  water  upon  a  coarsely-ground  glass  slab  until  a  creamy 
paste  is  formed.  Into  this  the  pieces  of  solder  may  be  placed,  and  also 
some  of  it  applied,  with  a  small  brush  or  feather,  to  the  surfaces  over 
which  the  solder  is  required  to  flow.  Hard  water  and  the  common 
practice  of  rubbing  borax  on  a  slate  make  it  impure,  and,  to  some 
extent,  interfere  with  soldering.  Too  much  borax  is  objectionable, 
and  gold  requires  less  than  silver. 

In  fulfilling  the  third  condition — the  management  of  the  heat — 
the  following  points  demand  attention:  (a)  To  raise  the  heat  very 
gradually,  until  the  water  of  crystallization  of  the  borax  is  slowly 
driven  ofi*;  for,  if  this  is  done  rapidly,  the  borax  pufis  up  and  thro\Vs 
ofi"  the  solder ;  rapid  heating  at  the  outset  is  apt  also  to  crack  the  teeth. 
(6)  To  diflrise  the  heat  when  using  the  blowpipe,  so  that  the  solder 
shall  not  become  melted  before  the  metallic  surfaces  are  hot  enough  to 
unite  with  it ;  else  it  will  roll  into  a  ball,  or  flow  with  an  abruptly- 


PRINCIPLES   AND   APPLIANCES   OF  SOLDERING. 


749 


Fig.  552. 


defined  edge ;  whereas  it  should  unite  so  smoothly  with  the  plate  that, 
except  for  the  difference  in  color,  its  line  of  termination  cannot  be 
detected,  (c)  To  manage  the  fine  point  of  the  blowpipe  flame  so  as 
to  be  able  to  direct  the  flow  of  the  solder  to  any  given  point ;  the  rule 
being  that,  unless  prevented,  solder  will  flow  toward  the  hottest  point. 
There  are  two  kinds  of  flame  given  by  the  blast  of  the  blowpipe:  1. 
The  broad,  heating-up  or  oxidizing  flame;  this  is  produced  by  holding 
the  tip  a  little  behind  or  at  the  edge  of  the  flame.  2.  The  pointed,  sol- 
dering or  deoxidizing  flame;  this  is  produced  by  passing  the  tip  more  or 
less  into  the  flame.     A  very  general  mistake  is  to  use  too  strong  a  blast. 

The  apparatus  required  for  soldering  includes  a  lamp  to  give  a  suffi- 
ciently hot  flame ;  a  blowpipe,  to  give 
intensity  and  direction  to  the  flame ; 
borax,  brush,  glass,  slate,  solder  and 
solder  tongs ;  investing  materials 
and  clamps,  to  protect  the  teeth, 
also  to  hold  the  parts  in  relation  to 
each  other  until  soldered ;  a  recep- 
tacle to  retain  or  give  additional  heat 
during  the  process  of  soldering;  an 
acid  (sulphuric)  bath,  to  remove  the 
glass  of  borax. 

The  simplest  form  of  lamp  is  shown 
in  Fig.  552,  holding  about  a  pint,  and  having  a  wick  three-fourths  of 
an  inch  or  one  inch  in  diameter.  As  accidents  sometimes  occur  from 
the  flame  communicating  with  the  explosive  mixture  of  air -and  alco- 
holic vapor  in  the  body  of  the  lamp,  it  is  prudent  to  make  a  safety 
lamp  by  connecting  the  wick  tube  with  the  body  of  the  lamp  by  a 
small  tube,  which  shall  be,  under  all  circumstances,  full  of  alcohol. 
Fig.  553  represents  such  a  lamp.  If  the  wick  is  not  permitted  to  run 
below  the  shoulder  above  the  horizontal  tube,  this  tube  will  remain 
always  filled  with  alcohol.  The  top  of  the  wick  tube  should  be  beveled 
oflT  in  a  direction  just  the 
reverse  of  that  shown  in 
the  drawing,  so  as  to  permit 
the  downward  projection  of 
the  flame.  Fig.  554  is  a 
very  ingenious  modification 
of  the  safety  lamp,  made 
by  Dr.  B.  W.  Franklin,  so 
constructed  as  to  retain  the 
alcohol  uniformly  at  the 
same  level. 


Fig.  553. 


750 


MECHANICS. 


Fig.  554. 


made  more  useful. 


The  fluid  used  in  these  lamps  is  usually  alcohol.     For  all  purposes 

of  dental  soldering  alcohol  gives  a  suf- 
ficient degree  of  heat,  and  is  much  more 
cleanly  than  the  carboniferous  flame  of 
ethereal  oil,  sperm  oil,  coal  oil,  or  gas. 
To  give  intensity  and  proper  direc- 
tion to  the  heat  of  the  lamp,  a  blow- 
pipe is  necessary.  The  simplest  is  a 
tapering  tube,  fifteen  to  eighteen  inches 
long,  and  curved  at  the  smaller  end 
(Fig.  555).  At  this  end  the  bore  for 
the  last  half  inch  should  be  perfectly 
cylindrical,  and  about  as  large  as  a 
medium-sized  knitting  needle.  This 
may  be  modified  in  several  ways,  and 
First,  by  cutting  it  within  three  inches  of  the 
flame  end,  and  inserting  a  small  hollow  ball  or  cylinder,  to  receive  the 

condensed    mo'isture, 
Fig.  555.  which,  in  the  plain  blow- 

pipe, often  interrupts 
the  blast.  Secondly,  by 
attaching  a  flattened 
mouth  piece,  which  it  is  much  less  fatiguing  to  the  lips  to  grasp. 
Thirdly,  by  connecting  the  flame  end  to  the  mouth  piece  by  from  six 
to  twelve  inches  of  flexible  tubing.  The  flame  end  ought  to  be 
straight,  and  from  four  to  six  inches  long ;  a  cigar  holder  makes  an 
excellent  mouth  piece.  A  bulb  or  enlargement  in  the  tube  might  be 
serviceable  in  retaining  condensed  moisture  ;  but  it  is  less  liable  to 
accumulate  in  rubber  tubing  than  in  the  metal  pipes.  There  are 
many  forms  of  mouth  blowpipes,  and  some  quite  expensive  ones  ;  but 
the  pipe  with  flexible  tube,  as  here  described,  will  be  found  very 
convenient  for  the  laboratory. 

Figs.  556,  557  and  558  represent  different  forms  of  blowpipes 
devised  for  the  purpose  of  preventing  the  moisture  which  accumulates 
within  the  tube  from  being  blown  from  the  orifice  and  interrupting  the 

blast. 

Figs.  557  and  558  are  modifications  introduced  by  Mr.  Thomas 
Fletcher,  and  for  the  latter  it  is  claimed  that  the  mouth  piece  is  the 
easiest  to  use,  and  the  heaviest  continued  blowing  causes  no  strain  on 
the  lips,  while  the  tongue  has  the  necessary  control  over  the  opening. 
Being  held  as  a  pencil,  the  chamber  on  the  stem  stops  all  condensed 
moisture  and  prevents  the  heat  ascending  to  the  end. 

The  mouth  blowpipe  requires  in  its  use  a  peculiar  management  of 


PEINCIPLES   AND   APPLIANCES   OF   SOLDERING. 


751 


the  muscles  of  the  chest,  cheeks  and  palate,  by  virtue  of  which  an 
uninterrupted  and  regular  current  of  air  is  thrown  from  the  lungs 
through  the  pipe.  The  simplest  way  to  learn  how  to  do  this  is  to  first 
practice  blowing  exclusively  during  mspiration  ;  this  calls  into  action 
the  cheek  muscles,  and  involuntarily  closes  the  opening  between  mouth 
and  fauces.  Then  use  the  pipe  solely  during  e.Tpiration ;  this  teaches 
control  of  the  chest  muscles  in  the  emission  of  a  steady,  gentle  blast. 
The  art  of  using  the  blowpipe,  without  fatigue,  consists  in  alternating 
the  action  of  these  two  sets  of  muscles ;  the  art  of  giving  a  perfectly 
steady,  uninterrupted  blast  implies  complete  control  over  these  muscles, 
and  the  ability  to  pass  from  one  set  to  the  other  at  the  moment  of 

Fig.  556. 


Fig.  557. 


Fig.  r)58. 


opening  or  closing  the  entrance  to  the  fauces.  After  persevering  prac- 
tice of  the  two  methods  of  blowing,  the  art  of  connecting  them  will 
come  almost  unconsciously;  when  once  learned,  it  is  never  forgotten. 
Those  who  are  too  indolent  to  master  the  first  difficulty  of  learning  it, 
become  the  slaves  to  mechanical  appliances  which,  however  useful  for 
many  purposes,  can  never  supply  the  place  of  this  simplest  and  best  of 
all  blowpipes. 

Blowpipes  working  by  artificial  blast  may  be  divided  into  four 
classes:  1.  Alcoholic  or  self-actiug  blowpipes;  2.  Mechanical  or  bel- 
lows blowpipes  ;  3.  Hydrostatic  blowpipes  ;  4.  Oxy-hydrogen  or  aero- 
hydrogen  blowpipes.     Of  each  of  these  we  shall  give  an  example.     To 


752 


MECHANICS. 


enumerate  all  the  forms  that  inventive  talent  has  devised  would  fill  too 
much  of  our  space. 

The  SELF-ACTING  blowpipes  derive  the  force  of  their  blast  from  the 
vapor  of  hot  alcohol,  ■which,  igniting  as  it  passes  through  the  flame, 
adds  to  the  intensity  of  the  heat.  A  somewhat  complex,  but  very 
complete,  blowpipe  of  this  class,  invented  by  Dr.  Jahial  Parmly,  is 
shown  in  Fig.  559. 

Fig.  55f». 


Fig.  560. 


The  lamp,  g,  supplied  from  the  reservoir,  D  D,  heats  the  alcohol  in 
globe,  I,  supplied  from  the  reservoir,  j,  through  the  pipe,  n.  The  elas- 
tic vapor  escapes  at  the  jet,  p,  giving  intensity  to  the  large  flame,  L, 
which  receives  its  supply  of  alcohol  from  reservoir,  ii  j.  Both  upper 
and  lower  wick  tubes  have  movable  cylinders  for  regulating  the  flame. 
A  small  charcoal  furnace,  E,  may  be  brought  in  range  of  the  flame 
for  melting  purposes. 

Smaller  and  more  portable  lamps  are  made,  of  which  quite  a  num- 
ber of  different  patterns  are  to  be 
found  in  the  depots.  The  principle 
and  general  plan  of  construction  are 
very  clearly  shown  in  Fig.  560,  de- 
signed by  Dr.  S.  S.  White.  All  al- 
coholic blowpipes  give  intensity  of 
heat,  but  are  greatly  inferior  to  the 
mouth  blowpipe  in  the  control  which 
the  operator  has  over  the  force  and 
direction  of  the  jet. 

The    different   forms   of  the   me- 
chanical blowpipe  are   almost  infi- 
rm nite.     The  principle  of  construction 
is  either  that  of  the  bellows  or  the 


PRINCIPLES   AND   APPLIANCES   OF   SOLDERING. 


753 


Fig 


force  pump  combined  with  a  reservoir  of  air  to  give  uniformity  to  the 
blast,  which  would  otherwise  issue  in  jets. 

A  common  house  bellows,  secured  to  the  floor,  will  form  a  simple 
and  good  arrangement.  A  spring  should  separate  the  handles,  the 
upper  one  of  which  forms  a  treadle.  An  India-rubber  pipe  should 
pass  from  the  nozzle  to  an  air-tight  box,  from  which  a  second  tube 
comes  out  and  is  attached  to  the 
blowpipe.  If  the  bellows  is  made 
double,  like  a  blacksmith's,  the 
upper  half  forms  the  air  chamber, 
in  place  of  the  air-tight  box. 

Fig.  561  represents  the  Burgess 
blowpipe,  which  is  a  convenient 
and  efiicient  form.  A  is  the  cyl- 
inder of  the  pump,  which  is  22 
inches  in  diameter,  allowing  a 
3-inch  stroke.  B,  piston  rod.  c  is 
heel-and-toe  treadle  for  driving  the 
pump.  D,  the  receiver,  12  inches 
high  by  3  inches  in  diameter,  into 
W'hich  the  air  is  forced.  The  whole 
height  of  the  machine  is  24  inches ; 
the  base  is  12  inches  by  5. 

Figs.  562  and  563  represent 
Fletcher's  bellows  blowpipes,  capa- 
ble of  being  adjusted  in  any  desired 
position. 


Fig.  563. 


Figs.  564  and  565  represent  two  forms  of  the  Fletcher  automatic 
blowpipe,  one  of  which  is  mounted  on  a  ball  joint.  These  forms  are 
very  convenient  for  soldering,  especially  in  the  manufacture  of  gold 
crowns. 

48 


754  MECHANICS. 

Fig.  564.  Fig.  565. 


Fig.  566. 


Fig.  567. 


Fig.  568. 


Fig.  566  represents  a  style  of  foot  bellows  by  which  the  bellows  and 
automatic  blowpipes  are  operated.    Fig.  567  represents  a  carbon  block 
for  use  as  a  support  in  soldering.     It  is  a  perfect  non-conductor  and  much 
Fig.  569.  cleaner  than  charcoal.    Fig.  568  repre- 

sents a  carbon  cylinder,  the  cupped 
end  of  which  answers  as  a  good  sup- 
port for  small  cases,  such  as  crowns, 
while  soldering. 

Fig.  569  represents  Macomber's  gas 
blowpipe.  The  direction  of  the  point, 
1,  is  regulated  by  the  joint,  3,  and  the 
A  supply  of  gas  controlled  by  the  stop- 
'•.\  cock,  2.  The  air  is  supplied  from  the 
lungs,  or  from  some  form  of  mechanical 
or  hydrostatic  blowpipe,  through  the 
flexible  tube. 


PRINCIPLES   AND   APPLIANCES   OF   SOLDERING.  755 

The  THIRD  class  of  blowpipes  is  sometimes  combined  with  the  second 
to  regulate  the  blast,  or  with  the  first  to  intensify  it.  In  its  uncom- 
bined  form  it  consists  essentially  of  a  blowpipe  point  attached  by  a 
flexible  tube  to  an  air  chamber,  from  which  the  air  is  forced  by  the 
steady  pressui-e  of  water.  When  once  set  in  operation,  it  is  self-acting, 
and  in  this  respect  has  great  advantage  over  the  second  class.  This, 
with  the  perfect  regularity  of  the  blast,  makes  a  properly  constructed 
hydrostatic  blowpipe,  much  the  best  of  all  substitutes  for  the  lungs 
and  mouth  blowpipe. 

The  gasometer  of  the  nitrous  oxide  gas  apparatus  makes  a  very 
excellent  hydrostatic  blowpipe.  Its  form,  and  the  manner  of  using 
it,  are  so  familiar  to  dentists  as  to  render  any  illustration  or  descrip- 
tion unnecessary.  Any  required  force  of  blast  may  be  given  by 
detaching  the  counterpoise,  or  by  adding  weights  to  the  descending 
cylinder. 

Prof.  Austen  gives  the  following  description  of  a  simple  and  inex- 
pensive apparatus  suitable  for  laboratories  where  no  pressure  can  be 
had,  as  in  cities,  from  public  water  works.  "  Place  in  convenient  posi- 
tion a  strong  ten-gallon  water-tight  oak  cask,  two  feet  from  the  floor. 
Over  this,  and  two  feet  above  it,  place  a  second  of  the  same  size,  with 
a  movable  cover,  so  that  water  may  be  conveniently  poured  into  it. 
Connect  the  casks  by  a  tube  running  nearly  to  the  bottom  of  the  lower 
cask,  and  having  a  stop-cock,  a,  between  the  casks.  Into  the  top  of 
the  lower  cask  insert  a  stop-cock,  b,  to  which  attach  the  blowpipe  tube, 
and  into  the  bottom  a  larger  stop-cock,  c,  for  drawing  off  the  water. 
It  is  prepared  for  operation  thus :  close  all  the  stop-cocks,  and  fill  the 
upper  cask  to  within  an  inch  of  the  top  (if  too  full,  it  might  chance  to 
overflow  the  lower  cask  and  force  water  out  of  the  blowpipe  upon  the 
flame  and  work)  ;  then  open  stop-cocks  a,  b,  and  the  jet  will  issue  with 
a  force  proportioned  to  the  height  of  the  water.  If  too  strong,  it  may 
be  regulated  by  pressure  upon  the  elastic  tube,  or  by  partly  closing 
the  stop-cock.  Ten  gallons  of  air  will  suffice  for  any  ordinary  case  of 
soldering ;  but  the  process  is  easily  renewed  by  closing  stop  a  and 
drawing  off  the  water,  by  stop  c,  from  the  lower  cask,  and  emptying 
into  the  upper.  This  can  be  more  rapidly  done  if  stop  b  is  left  open, 
so  as  to  admit  air  freely  while  drawing  off  the  water." 

Another,  but  more  expensive  form,  is  shown  in  Fig.  570,  made  of 
copper  or  boiler  iron,  and  connected  by  lead  pipes  with  the  public 
water  works,  in  towns  and  cities  thus  supplied.  The  drawing,  taken 
in  connection  with  the  previous  description,  makes  any  explanation 
unnecessary. 

The  fourth  class  of  blowpipes  is  analogous  in  its  operation  to  the 
oxy-hydrogen  blowpipe.     The  point  is  double,  consisting  of  a  tube, 


756 


irECHANICS. 


Fig.  570. 


C^^ 


--•^Jlllii 


through  which  comes  the  supporter  of  combustion  (oxygen  or  com- 
mon air),  surrounded  by  a  cylinder,  through  which  comes  the  combus- 
tible (alcoholic  vapor,  illuminating  gas,  or 
hydrogen).  In  Count  Kichmont's  aero- 
hydrogen  blowpipe,  the  hydrogen  is  gener- 
ated in  a  vessel  by  the  action  of  dilute  sul- 
phuric acid  upon  zinc,  and  the  air  forced 
through  the  centre  tube,  either  with  a  bel- 
lows or  from  the  lungs.  The  heat  is  less 
intense  than  that  of  the  oxy-hydrogen  blow- 
pipe, but  is  too  great  for  most  laboratory 
purposes.  The  gas  blowpipe  is  a  very  con- 
venient instrument ;  the  principle  is  simi- 
lar, and  the  heat  very  great. 

In  the  operation  of  soldering,  the  parts 
to  be  united  must  be  held  together  in  their 
exact  relative  position.  This  can  some- 
times be  done  by  simply  laying  them  to- 
gether ;  but  usually  they  must  be  held  in 
place,  either  by  iron  wire  bound  around 
them,  or  by  small  clamps  of  iron  wire,  or 
by  rivets ;  or  else  by  some  investing  material,  which,  in  dentistry,  is 
always  plaster  mixed  with  some  substances  that  will  counteract  its 
tendency  to  shrink  and  crack  under  soldering  heat.  This  substance 
may  be  coal  ashes,  soapstone  dust,  feldspar,  clean  sand,  or  asbestos. 
The  two  latter  are  the  best,  and  may  be  mixed  in  proportions  varying 
from  two  to  six  parts  sand  or  asbestos  to  four  of  plaster.  As  a  rule, 
the  less  plaster,  the  less  shrinkage;  but  a  very  small  quantity  makes 
the  investment  too  friable. 

A  common  mistake  is  to  use  too  large  a  quantity  of  investing 
material.  This  almost  invariably  results  in  the  warping  of  the  plate ; 
for,  as  all  investments  have  some  degree  of  permanent  contraction,  and 
all  metal  must  expand,  if  the  latter  is  bound  by  a  rigid,  unyielding 
mass,  it  will  inevitably  warp.  Hence,  as  a  rule,  use  no  more  investing 
material  than  is  necessary  to  keep  the  parts  to  be  soldered  in  their 
position,  and  to  protect  the  porcelain  surfaces  from  direct  contact  with 
the  flame.  This  subject  will  be  further  considered,  when  speaking  of 
the  soldering  of  teeth  to  the  plate. 

In  selecting  a  suitable  receptacle  for  the  work  to  be  soldered,  it  is 
important  to  retain  the  heat,  especially  when  using  the  mouth  blow- 
pipe. A  funnel-shaped  mat  made  with  scraps  of  Avoven  iron  wire,  or 
a  large  lump  of  pumice  stone,  or  one  of  close-grained  charcoal,  with 
the  outside  coated  over  with  a  thin  layer  of  plaster,  form  very  simple 


PRINCIPLES   AND   APPLIANCES   OF   SOLDERING. 


757 


and  convenient  receptacles  for  smaller  pieces  of  work.  For  larger 
work,  or  for  very  high  temperatures,  it  is  important  to  receive  addi- 
tional heat  from  ignited  charcoal,  for  which  purpose  the  soldering  pan 
(Fig.  571)  is  a  very  admirable  contrivance.  The  movable  lid  remains 
during  the  heating  up  and  the  cooling  off,  but  is,  of  course,  removed 
during  the  act  of  soldering. 

After  soldering,  the  work  should  cool  gradually,  unless  it  is  to  be 
re-swaged.  If  there  is  any  porcelain  attached,  the  cooling  must  be 
very  gradual.  When  cold,  it  may  be  placed  in  dilute  sulphuric  acid 
and  slowly  raised  to  the  boiling  point,  kept  there  for  a  few  moments, 
and  then  slowly  cooled.  This  dissolves  the  glass  of  borax,  which  is 
so  hard  that  it  injures  the  edge  of  files  and  scrapers. 

Fig.  571. 


A  few  general  considerations  may  be  of  service  in  the  use  of  the 
above  described  appliances  for  soldering.  It  is  an  operation  regarded 
by  many  as  attended  with  much  risk ;  and  by  students  generally  it  is 
considered  the  j^ons  asinorum  of  dentistry.  Whereas,  there  is  no  pro- 
cess in  dental  prosthesis  in  which  the  desired  result  can  be  with  more 
certainty  obtained,  provided  such  care  and  skill  are  exercised  as  alone 
can  give  success  in  any  department  of  the  art. 

Plates  warp,  from  want  of  support  when  heated,  or  from  excess  of 
investing  batter;  they  are  burnt,  blistered,  or  melted,  from  careless  or 
ignorant  use  of  the  blowpipe.  Teeth  are  broken,  from  rapid  heating 
or  cooling;  they  are  displaced  by  the  shrinking  of  an  ill-judged  invest- 
ment.    Solder  is  condemned  because  it  will  not  bridge  a  chasm  one- 


758  MECHANICS. 

eighth  of  an  inch  wide,  will  not  run  over  plaster,  will  not  attach  itself  to 
an  oxidized  surface,  or  will  obstinately  roll  up  into  a  ball,  rather  than 
flow  over  a  surface  too  cold  to  receive  it.  These,  and  all  other  vexa- 
tions of  soldering,  are  the  result  of  haste,  ignorance,  or  want  of  skill. 

In  soldering  two  surfaces,  as  in  the  doubling  of  lower  or  shallow 
upper  plates,  the  borax  must  contain  no  particles  preventing  contact 
of  the  plates ;  also  the  heat  must  be  directed  on  the  side  opposite  the 
pieces  of  solder,  so  that,  when  melted,  it  may  flow  between  the  plates 
from  one  side  to  the  other.  Clamps  are  preferable  to  plaster  batter 
for  holding  parts  together,  whenever  practicable,  as  in  soldering  a  wire 
or  band  around  plates;  but  when  the  relation  must  be  preserved  with 
utmost  accuracy,  as  in  clasps,  the  plaster  investment  is  essential.  It  is 
also  necessary  for  the  protection  of  porcelain  from  the  direct  action  of 
flame. 

In  soldering  teeth  to  a  plate,  the  batter  must  have  such  proportion 
of  plaster  with  asbestos  or  sand  as  to  admit  of  being  used  in  small 
quantity,  and  yet  be  so  strong  when  heated  that  it  will  not  crack,  and 
endanger  the  position  of  the  teeth.  Backings  and  clasps  must  fit  accu- 
rately wherever  they  are  to  be  fastened.  There  should  be  no  trace  of 
plaster  on  a  surface  where  solder  is  to  flow ;  or,  in  fact,  substances  of 
anv  kind  except  borax,  and  not  too  much  of  that.  Borax  must  be 
pure  and  clean,  and  used  with  soft  water,  and  the  heating  must  be 
gradual,  in  view  of  its  liability  to  throw  off  the  solder.  Solder  must 
be  of  good  quality  and  carefully  placed,  never  putting  two  pieces 
where  the  position  will  allow  the  proper  quantity  to  lie  in  one  piece. 
It  is  a  very  common  practice  to  cut  solder  into  very  small  pieces,  under 
the  idea  that  it  will  flow  more  evenly ;  but  if  a  plate  is  properly  heated 
and  the  blow^pipe  flame  skillfully  managed,  the  large  pieces  melt  in- 
stantly, and  flow  into  their  proper  position. 

It  is  quite  possible,  by  careful  observance  of  these  directions,  and  by 
expertness  in  the  management  of  the  blowpipe,  to  solder  any  set  of 
teeth  so  that  there  shall  be  no  roughness  or  abrupt  edges  requiring 
the  use  of  files  and  scrapers.  In  fact,  these  tools  are  never  needed  to 
give  finish  to  a  perfectly  soldered  joint ;  the  natural  flow  of  the  solder 
takes  a  shape  which  cannot  be  improved. 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE.        759 


CHAPTER  XII. 

ADJUSTMENT   OF   PORCELAIN   TEETH   TO   THE   PLATE — FINISHING 

PROCESS. 

WHERE  vacancies  between  natural  teeth  are  to  be  filled,  it  is 
highly  important  that  the  artificial  teeth  should  correspond  in 
shade  and  color  with  the  natural  organs ;  for  in  proportion  as  they  are 
whiter  or  darker,  will  the  contrast  be  striking,  and  their  artificial 
character  apparent.  Of  the  two  faults,  it  is  better  that  they  should 
be  a  little  darker  than  any  whiter.  They  should  also  resemble  in 
shape  those  which  have  been  lost,  so  far  as  it  is  possible  to  ascertain 
this.  Minute  accuracy  as  to  shades  of  color  involves  the  necessity  of 
a  large  assortment,  unless  one  is  located  near  a  depot  or  agency.  But 
the  facilities  of  mail  and  express  greatly  lessen  this  necessity,  provided 
there  is  time  to  send  for  the  tooth  or  teeth  required.  It  is  desirable,  in 
view  of  this  method  of  matching  shades  of  color,  to  keep  all  refuse  or 
broken  teeth,  to  be  used  as  samples  in  sending  orders. 

The  manufacturer  supplies  three  varieties  of  plate  teeth — plain, 
gum,  and  sections.  The  latter  have  the  advantage  of  showing  few 
joints,  but  are  less  easily  repaired,  and  are  not  applicable  to  so  wide 
a  range  of  cases.  Gum  teeth  or  sections  are  applicable  only  where 
there  have  been  sufiicient  absorption  to  permit  the  extra  fullness  of  the 
artificial  gum.  Many  mouths  are  deformed  by  a  foolish  craving  on  the 
part  of  the  patient,  which  the  dentist  is  equally  foolish  in  yielding  to, 
whenever  plain  teeth  are  more  appropriate.  In  point  of  strength, 
durability,  and  facility  of  repair,  plain  teeth  are  superior  to  the  others  ; 
they  are  also  more  readily  adapted  to  the  plate. 

The  manufacture  of  gum  teeth,  in  sections  of  two,  three  or  four 
teeth,  has  been  brought  to  such  perfection  that  comparatively  few 
single  gum  teeth  are  now  used  ;  especially  since  new  methods  of 
attaching  these  sections  to  the  plate  have  rendered  unnecessary  that 
exact  fitting  of  blocks  which  was  one  objection  to  their  use.  This 
perfection  of  manufacture  has  also  done  away  with  the  necessity,  on  the 
part  of  the  dentist,  of  devoting  to  the  making  of  block  teeth  the  very 
large  proportion  of  his  time  formerly  demanded  by  this  difficult 
process.  Whenever  special  cases  demand  blocks  or  sections  made  to 
order,  it  will  be  found  more  satisfactory  to  send  proper  models  and 
descriptions,  and  have  such  teeth  made  by  those  who  are  thus 
constantly  occupied,  than  to  incur   the  disappointments  and  delays 


760 


MECHANICS. 


inevitably  attendant  upon  infrequent  and  irregular  attempts  at  block 
work. 

For  the  proper  shaping  of  models  or  articulators  to  accompany  such 
orders,  directions  will  hereafter  be  given.  These  blocks,  when  received, 
do  not  need  much,  if  any,  grinding.  But  all  plain  teeth,  single  gum 
teeth,  and  ordinary  sections  or  block  teeth  require,  after  selection,  to 
be  more  or  less  accurately  fitted  to  the  base  plate.  For  this  purpose 
they  must  be  ground  on  emery  or  corundum  wheels  until  accurately 
fitted,  and  must  be  so  arranged,  in  full  cases,  as  to  meet  the  teeth  with 
which  they  are  intended  to  antagonize  at  the  same  instant  around  the 
entire  arch  ;  in  partial   cases,  the  natural   teeth  should  touch  their 


\ 


antagonists  more  decidedly  than  the  artificial  ones.  A  correct  articu- 
lation will  enable  the  dentist  to  antagonize  the  teeth  with  perfect 
accuracy. 

In  arranging  an  entire  set  for  the  upper,  or  for  both  jaws,  the  molars 
should  be  so  adjusted  that  the  inner  or  palatine  tubercles  come  together 
before  the  outer  ones.  This  precaution  is  necessary  in  antagonizing 
single  as  well  as  block  teeth.  If  the  outer  tubercles  strike  first,  the 
pressure  there  will  spring  and  loosen  the  plate.  For  the  same  reason 
upper  molars  and  bicuspids  should  not  be  set  so  that  the  force  of 
mastication  falls  outside  of  the  ridge.     A  small  space  should  be  left 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE. 


761 


between  the  last  tooth  of  the  upper  and  of  the  lower  jaw,  in  those  cases 
where  the  crown  of  the  lower  molar  looks  forward,  its  posterior  edge 
being  a  little  higher  than  the  anterior. 

It  is  often  necessary  to  cut  away  a  considerable  portion  of  a  tooth, 
in  order  to  make  it  fit  accurately  to  the  plate.  This  makes  the  process 
of  grinding  very  tedious,  unless  the  operator  has  a  number  of  sharp- 
cutting  corundum  wheels,  varying  from  half  an  inch  to  three  or  four 
inches  in  diameter. 

Fig.  572  represents  an  excellent  form  of  corundum  wheel  (the 
Fig.  573.  Fig.  575. 


Fig.  574. 


762 


MECHANICS. 


Fig.  576. 


suggestion  of  Dr.  S.  Lee),  for 
jointing  porcelain  gum  teeth, 
and  is  made  of  various  grits. 

These  wheels  may  be  at- 
tached to  a  hand  lathe,  such 
as  represented  by  Fig.  423,  or 
to  Coy's  noiseless  hand  lathe 
(Fig.  573).  The  foot  lathe  is, 
however,  far  more  convenient 
for  laboratory  use,  where 
much  grinding  is  to  be  done. 
Of  these,  the  depots  furnish 
some  excellent  varieties.  Figs. 
574  and  575  represent  the 
Snowden  &  Cowman  and  the 
S.  S.  White,  which  are  admir- 
able lathes  for  dental  purposes,  while  in  Fig.  576  we  have  the  Amateur 
lathe,  which  is  a  larger,  stronger  and  more  powerful  lathe,  capable  of 
very  rapid  motion ;  also  adapted  to  the  making  of  small  instruments, 
handles,  etc. 

The  lathe  of  Dr.  Lawrence,  with  detached  driving  wheel  and  head, 
that  can  be  attached  to  any  convenient  board,  shelf  or  table  (Fig.  577), 
has  advantages  that  will  make  it  very  desirable  to  many. 

Fig.  577. 


Wheels  may  either  be  set  at  intervals  on  a  long  spindle,  or 
screwed  singly  on  the  end  of  the  mandrel  (Fig.  577).  In  the  latter 
case  they  should  be  fixed  with  a  screw  chuck  in  the  centre,  so  as  to  be 
quickly  changed  from  coarse  to  fine,  or  from  large  to  small.  In 
grinding,  the  wheel  should  revolve  toward  the  operator,  and  be  kept 
constantly  wet  with  a  sponge  held  either  in  a  sponge  holder  or  between 
the  ring  finger  and  little  finger  of  the  left  hand. 


ADJUSTMENT   OF   TEETH    TO   THE    PLATE. 

Fig.  578. 


76; 


The  thumb  and  forefinger  of  each  hand  must  be  free  to  hold  the 
tooth,  the  right  wrist  being  steadily  supported  on  the  hand  rest  (Fig. 
578).  Two  faults  are  very  common  in  grinding:  one  is,  revolving  the 
wheel  too  rapidly ;  the  other,  bearing  the  tooth  too  heavily  against  the 
wheel.  The  first  hinders  rather  than  helps  grinding ;  the  second  is 
very  apt  to  throw  the  tooth  from  the  fingers,  and  destroys  the  delicacy 
of  touch  necessary  for  accurate  grinding. 

Fig.  579  represents  the  cone-journal  lathe  head,  which  is  also  ope- 

FiG.  579. 


764 


MECHANICS. 


580. 


m] 


rated  by  a  driving  wheel,  and  can  be  attached  to  a  table,  and  is  an 
admirable  appliance. 

In  grinding  blocks  and  gum  teeth,  and  often  in  plain  teeth,  very 
small  wheels  are  required,  to  make  them  fit  the  curves  of  the  plate. 
Thin  edges  of  gum  teeth  and  blocks  must  be  ground 
with  very  fine-grained  wheels;  in  jointing  them  a 
three-inch  wheel  should  be  used,  perfectly  flat  on  its 
outer  side,  and  running  very  true.  Wheels,  when 
worn  down  to  small  size,  increase  in  value,  because 
they  grind  out  curves  inaccessible  to  larger  ones.  In 
warm  weather  large  and  thin  wheels,  when  not  in  use, 
should  rest  on  a  flat  surface;  such  wheels  are  often 
Avarped  by  the  softening  of  the  shellac  as  they  lie 
carelessly  among  other  wheels.  Wheels  running  on 
the  end  of  a  mandrel,  and  attached  by  a  screw  chuck, 
can  be  made  to  run  true  by  warming  the  mandrel 
with  a  spirit  lamp,  and  at  the  same  time  revolving 
the  wheel  rapidly. 

The  accuracy  of  fit  necessary  depends  upon  the 
kind  of  work  and  mode  of  attachment  to  the  base 
plate.  In  general  terms,  it  may  be  stated  that  when- 
ever any  permanent  plastic  material  is  in  contact  with 
the  base  of  the  teeth,  or  forms  the  bond  of  union 
between  the  teeth  and  plate,  grinding  is  much  sim- 
plified. It  is  sometimes  better,  in  such  cases,  to  have 
a  moderate  space  between  the  base  of  the  tooth  and 
the  plate  or  the  model,  than  to  have  actual  contact. 
But  in  all  cases  the  lateral  jointing  of  block  or  single 
gum  teeth  requires  care. 

The  order  of  grinding  a  set  of  teeth  is  usually 
to  fit  the  central  incisors,  then  the  laterals,  next  the 
bicuspids,  and  so  on  ;  in  case  of  sections,  in  the  same 
order.  This  order  will  be  found  most  conducive  to 
uniformity  of  arrangement ;  of  course,  it  may  be  modi- 
fied to  any  desired  extent.  In  case  of  a  double  set, 
there  is  much  diversity  of  practice.  Some  adapt, 
first,  the  entire  upper  set,  others,  the  entire  lower ;  some,  again,  adjust 
the  two  sets  of  incisors,  then  the  bicuspid  blocks  of  both  pieces,  lastly, 
the  molars.  Whichever  method  is  adopted,  when  all  or  part  of  one  of 
the  articulating  rims  is  removed,  the  antagonizing  rim  must  be  re- 
tained, to  guide  in  the  adjustment  of  the  teeth. 

Fig.  580  represents  a  holder  for  teeth  while  grinding;  a  slot  admits 
the  pins,  and  the  side  clamp  holds  the  tooth  securely. 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE.        765 

During  the  process  of  grinding,  the  teeth  are  teraporarily  attached 
to  the  plate  in  several  ^vays.     Either  the  articulating  rim  is  cut  away 
sufficiently  to  receive  the  tooth  (Fig.  581), 
or  the  rim  is  entirely  removed,  and  its  place  ^^^-  ^^1- 

supplied  with  a  mass  of  wax  covering  the 
plate  to  the  top  of  the  ridge,  and  to  which 
the  teeth  are  severally  attached  as  they  are 
ground  ;  others  fasten  the  teeth  to  the  plate 
with  cement.  Dr.  Richardson  gives  the  fol- 
lowing formula  for  a  tenacious  wax  for  tem- 
porarily securing  the  teeth  :  Beeswax,  fb  j  ; 
gum  mastich,  E  ij  ;  Spanish  whiting,  §  j. 

Definite  rules  of  arrangement,  or  wood-cuts  illustrating  various 
forms  of  teeth  and  manner  of  setting  them  in  the  arch,  are  not  all 
that  is  necessary.  This  branch  of  dental  sesthetics  must,  of  necessitv, 
be  worked  out  by  every  one  for  himself  He  will  succeed  or  fail  just 
in  proportion  as  he  has  the  ability  to  observe  the  hundreds  of  models 
which  are  perpetually  before  him  ;  and  as  he  has  the  further  and  rarer 
ability  to  apply  his  observations  to  the  special  cases  that  are  in  his 
laboratory. 

Imitation  of  nature  is  the  rule.  Limitations  of  art,  and  individual 
incapacity,  make  exact  observance  of  this  rule  comparativelv  rare. 
We  replace  the  sixteen  teeth  with  only  fourteen,  and  often  make  them 
shorter  and  every  way  smaller  than  the  natural  organs.  We  do  not 
make  the  grinding  surfaces  interlock  with  such  deep  cusps  as  in  nature. 
At  one  time  we  cannot  avoid  an  unnatural  fullness  of  artificial  gum  ; 
at  other  times,  the  contraction  of  the  absorbed  arch  compels  the  set- 
ting of  molar  teeth  nearer  the  median  line  than  the  original  teeth. 

Notwithstanding  these  and  many  other  disadvantages,  the  perfection 
of  the  den  to-ceramic  art  is  such  that  a  skilled  artist,  who  is  quick  to 
observe  what  nature  requires,  can,  in  the  majority  of  cases  falling 
under  his  care,  supply  the  lost  dental  organs  with  great  accuracy,  and 
preserve  that  higher  order  of  beauty  which  grows  out  of  the  harmony 
of  his  work  with  the  expression  of  the  face  and  entire  person.  But 
no  dentist  can  give  to  his  work  this  kind  of  beauty  who  does  not  sys- 
tematically study  the  natural  organs  as  they  daily  present  themselves 
in  the  operating  chair.  Few  patients  would  object  to  the  pressure  of  a 
roll  of  wax  (two  inches  long  and  about  half  an  inch  thick)  against  the 
closed  teeth.  A  model  from  this  impression  would  give  the  size,  form, 
arrangement,  and  articulation  of  all  except  the  molar  teeth.  A  well- 
matched  porcelain  tooth  (more  than  one  might  be  required)  would  add 
to  these  data  the  color  of  teeth  and  gum.  To  this  add  also  the  age, 
sex,  physical  characteristics  of  the  face,  and  the  physical  temperament. 


766  MECHANICS. 

If  the  dentist  would  have  a  case  book  for  the  registration  of  one 
such  carefully  made  observation  every  week,  he  would,  at  the  end  of 
two  years,  have  a  collection  which,  as  a  practical  guide  in  the  selec- 
tion and  arrangement  of  artificial  teeth,  would  prove  of  incalculable 
value.  These  fixed  records  of  minute  details  are  made  still  more  use- 
ful by  a  habit  of  close  observation  in  society.  In  this  way  a  set  style, 
or  mannerism,  may  be  avoided,  which  so  often  stamps  dental  work 
with  meaningless  uniformity  of  expression. 

Artificial  teeth  should  imitate  the  natural  organs  ;  yet  there  is  a 
perfection  of  form  and  arrangement  which  it  is  not  advisable  to  imi- 
tate. To  disarm  suspicion  as  to  their  artificial  character,  it  is  often 
desirable  to  impart  a  measure  of  irregularity.  An  overlapping  lateral, 
a  missing  bicuspid,  a  worn  canine,  an  incisor,  bicuspid  or  molar  ap- 
parently decayed  and  filled  with  gold,  an  exposed  neck  from  absorp- 
tion of  the  alveolus,  are  among  the  legitimate  devices  of  the  skillful 
mechanician  who  has  the  "  art  to  conceal  his  art."  If  there  are  any 
defective  natural  teeth  remaining  to  be  matched,  still  higher  art  is  re- 
quired. A  perfect  porcelain  incisor  is  no  fit  companion  for  one  that  is 
partly  broken,  decayed  and  discolored  ;  and  since  no  art  can  make  the 
defective  tooth  perfect,  and  yet  the  patient  retains  it,  there  is  no  alter- 
native but  to  give  so  much  imperfection  to  the  artificial  one  as  shall 
take  away  that  striking  contrast  which  so  painfully  offends  our  aesthetic 
sense  of  fitness. 

In  this  class  of  operations  a  "  diamond  drill  "  is  of  great  value ;  in 
fact,  so  very  useful  is  it  in  many  ways,  that  we  regard  it  as  an  abso- 
lutely indispensable  instrument  in  the  laboratory.  Cutting  away  parts 
of  teeth  or  blocks  inaccessible  to  wheels ;  changing  the  shape  of  teeth 
near  the  gum;  drilling  cavities  to  be  filled  with  gold,  or  holes  for  the 
repair  of  broken  blocks,  these  are  some  of  the  operations  which  the 
diamond  drill  will  accomplish  as  no  other  instrument  can. 

The  selection  and  grinding  of  artificial  teeth  requires,  first,  a  high 
order  of  aesthetic  culture  ;  secondly,  great  patience  and  skillful  manipu-. 
lation.  The  latter  are  often  taxed  to  the  utmost  to  make  a  set  of 
blocks  answer  the  requirements  of  a  given  case ;  especially  when  the 
blocks  must  be  closely  fitted  to  a  gold  plate  preparatory  to  attachment 
by  soldering.  Single  gum  teeth  are  more  easily  fitted  to  the  plate ; 
but  there  are  more  joints ;  hence  it  is  doubtful  if  much  time  is  saved. 
The  principal  advantage  of  single  gum  teeth  is,  that  a  single  tooth,  if 
broken,  may  be  replaced  without  interfering  with  the  adjoining  ones. 
Another  reason  why  many  prefer  them  is,  that  a  small  stock  of  teeth 
in  this  form  is  adapted  to  a  larger  variety  of  cases  than  blocks 
would  be. 

We  think,  however,  thai  dentists  living  at  a  distance  from  the 


ADJUSTMENT   OF   TEETH   TO   THE   PLATE. 


767 


manufacturer  should  depend  upon  a  great  variety  of  samples  rather 
than  upon  duplicates  of  certain  forms,  however  desirable.  It  is  a 
matter  of  some  surprise  that  manufacturers  have  not  long  ago  recog- 
nized the  advantage  of  preparing  "  sample  cards,"  numbered  and  let- 
tere(l ;  so  that  any  desired  size,  shape  and  color  of  teeth  may  be 
ordered  by  mail  or  express,  as  they  are  required.  These  samples 
should  be  so  made,  however,  that  the  "  card"  could  not  be  injured  by 
the  temptation  to  use  them  in  practice. 

In  jointing  a  set  of  blocks  or  single  gum  teeth,  one  point  must  be 
remembered  which  has  been  already  alluded  to.  In  soldering,  the 
metal  expands,  while  the  teeth  held  in  the  investment  are  brought 
closer  together  by  its  contraction,  and  in  this  slightly  altered  position 
they  are  soldered  to  the  plate.  The  contraction  of  the  plate  on  cool- 
ing is  irresistible,  and  may  result  in  one  or  both  of  the  two  accidents — 
chipping  off  the  brittle  edges  of  the  teeth  thus  brought  too  closely 
together,  or  warping  the  plate  because  of  the  resistance  which  the 
teeth  or  blocks  offer  to   the  contraction  of   the  plate.     Thin  letter 


Fig.  582. 


Fig.  583. 


paper  slipped  between  the  side  joints  will  suffice  to  prevent  these 
accidents. 

Fig.  582  gives  an  external  view  of  a  full  upper  set  of  single  gum 
teeth,  arranged  on  a  gold  plate,  preparatory  to  the  operations  which 
precede  soldering,  or  other  modes  of  fastening  them  to  the  base.  Fig. 
583  is  a  similar  view  of  a  set  of  blocks,  with  a  soldered  rim  covering 
the  upper  edge. 

Usually,  in  first  or  temporary  pieces,  and  sometimes  after  the 
alveolar  absorption  is  completed,  the  fullness  of  the  gum  is  such  as  to 
forbid  the  addition  of  an  artificial  gum  to  the  ten  incisors,  canines  and 
bicuspids.  In  such  cases  the  plate  must  be  cut  away  from  the  front  of 
the  ridge  as  far  as  the  first  or  second  bicuspid,  and  the  teeth  ground 
with  great  accuracy  to  fit  the  gum  itself.  Single  plain  teeth  will 
usually  be  best  adapted  to  such  cases  ;  but  an  excellent  effect  can 
sometimes  be  produced  by  grinding  a  block,  when  the  shade  of  gum  is 
well  matched,  to  fit  directly  upon  the  natural  gum.  In  partial  cases 
the  tooth  or  block  must  invariably  be  fitted  to  the  gum  ;  no  plate 


768 


MECHANICS. 


should  be  seen  above  or  at  the  side.  In  fitting  directly  to  the  plaster 
model,  this  should  be  scraped  (after  the  tooth  is  ground),  so  that  it  may 
press  firmly  on  the  corresponding  gum. 

The  teeth  or  blocks  being  now  arranged  and  fitted  to  the  plate,  the 
next  step,  preparatory  to  soldering,  is  to  get  access  to  the  pins  on  the 
inside,  for  the  purpose  of  backing  them.  Set  the  articulating  model  on 
the  table  with  the  teeth  upward  ;  bend  a  strip  of  lead  (an  inch  wide) 
outside  the  arch  and  about  half  an  inch  from  the  teeth  ;  then  fill  the 
space  with  plaster,  inserting  a  strip  of  tin  foil  opposite  the  median  line, 
so  that  the  plaster  rim  will  readily  break  at  that  point  when  removed. 
In  a  double  set  do  the  same  with  each  half  of  the  articulator.  When 
the  plaster  has  set,  remove  all  wax  or  cement  from  the  teeth  and  plate, 
and  proceed  to  examine  the  pins,  also  the  relations  of  the  teeth  or 
blocks  to  the  plate  and  to  each  other.  This  temporary  plaster  band 
we  regard  as  essential  in  every  case,  except  a  few  varieties  of  partial 
sets.  It  is  equally  essential  in  vulcanite  and  other  forms  of  plastic 
work,  as  will  be  hereafter  explained.  It  is  a  common  but  not  good 
practice,  where  the  teeth  are  soldered,  to  substitute  for  this  temporary 
band  the  soldering  investment. 

Fig.  584  will  give  an  idea  of  the  shape  of  this  rim,  except  that, 
being  here  designed  for  a  different  purpose,  it  does  not  show  the  im- 
press of  the  teeth.  Fig.  585  represents  the  inner  surface  of  a  set  of 
blocks  with  the  wax  removed,  which  we  may  suppose  just  withdrawn 


Fig.  584. 


Fig.  585. 


from  the  plate  in  preceding  figure.  Blocks  or  sections  are  readily 
replaced  in  their  proper  positions  ;  but  single  teeth  are  sometimes  so 
similar,  especially  bicuspids,  that  they  are  apt  to  be  misplaced.  To 
prevent  such  accidents,  have  a  circular  wooden  block,  four  inches  in 
diameter,  with  twenty-eight  cups  or  depressions,  so  marked  that  each 
tooth  can  be  instantly  put  into  and  taken  from  its  proper  cup. 

The  teeth  being  thus  arranged,  a  gold  plate,  or  backing  large  enough 
to  cover  the  entire  width,  and  from  eight-  to  nine-tenths. of  the  height 
of  the  posterior  surface  of  each,  is  fitted  to  them  in  the  following  man- 


ADJUSTMENT    OF   TEETH    TO   THE    PLATE. 


769 


ner.  Each  tooth  has  securely  fixed  in  the  back  part  of  it  two  platina 
•  rivets,  for  the  purpose  of  conuecting  it  to  the  backing.  Each  backing, 
therefore,  should  have  two  holes  punched  through  it  by  means  of  a 
pair  of  punch  forceps,  as  represented  in  Fig.  586,  large  enough  to 
admit  the  rivets  of  the  teeth.     After  having  punched  one  hole,  a  rivet 

Fig.  586. 


is  inserted;  then,  by  moving  the  strip  of  gold  plate  two  or  three  times 
to  the  right  and  left,  a  mark  will  be  left  upon  it,  indicatiog  the  dis- 
tance the  rivets  are  apart.  But  previously  to  this  the  rivets  should  be 
made  parallel  (being  very  careful  not  to  strain  them  in  the  tooth),  and 
the  ends  filed  off  level.  Otherwise  the  pins  will  not  go  into  the  holes 
punched,  and  there  will  be  an  uncertainty  as  to  w^hich  side  of  the  pin 
the  mark  on  the  plate  corresponds. 

Dr.  Samuel  Mallet  has  very  ingeniously  invented  a  punch  which 
will  save  much  trouble  in  finding  the  proper  position  of  the  second 
hole  (Fig.  587).     After  straightening  the  plus,  one  is  placed  in  the 

Fig.  587. 


49 


770  MECHANICS. 

hole,  i,  at  the  head  of  the  punch,  the  other  pin  pressing  out  the  mov- 
able punch,  e  (which  works  by  the  spring,  ^f),  until  it  slips  into  the  slot,, 
h;  the  two  punches,  /  e,  then  make  the  holes  at  the  exact  distances 
apart  to  receive  the  pins. 

A  simple  form  of  punch,  and  one  not  liable  to  accident,  is  a  piece 
of  steel,  half  an  inch  square  and  three  or  four  inches  long.  It  consists 
of  two  halves  riveted  together  at  the  top,  each  tapering  nearly  to  a  point. 
By  turning  a  small  screw,  inserted  midway  in  one  leg,  the  points  held 
opposite  the  pins  are  separated  to  their  exact  distance.  A  slight  tap 
of  the  hammer  marks  this  upon  the  backing,  and  then  the  holes  are 
made  with  an  ordinary  punch.  Pins  often  set  very  irregularly  in  a 
tooth ;  they  should  be  parallel,  but  not  necessarily  perpendicular.  Too 
much  bending  of  a  pin  close  to  the  tooth  makes  it  more  liable  to  frac- 
ture in  soldering,  or  by  use  in  the  mouth.  Pins  also  vary  much  in 
thickness;  it  is  better  to  have  the  pin  of  the  punch  forceps  of  medium 
size,  and  to   ream  with  a  broach  for  large  platina  pins.     A  set  of 

Fig.  588. 


broaches  are  indispensable  in  backing  teeth  and  in  many  other  opera- 
tions. 

The  holes  should  be  slightly  countersunk  on  both  sides,  and  after 
placing  the  backing  on  the  tooth,  it  is  made  fast  by  splitting,  with  a 
strong  knife  or  a  wedge-shaped  excavator,  the  ends  of  the  platina  rivets, 
or  pinching  them  together  Avith  pliers.  If  the  ends  of  the  platina  rivets 
are  hammered  so  as  completely  to  fill  the  holes  in  the  backings,  it  will 
prevent  the  solder  from  flowing  in  and  uniting  the  two  as  firmly  as  it 
should  do.  The  backings  should  be  slightly  hollowed  before  they  are 
put  on ;  by  so  doing,  they  will  fit  up  closely  to  every  part  of  the  back 
of  the  tooth.  Fig.  588  represents  a  pair  of  forceps  designed  to  give 
a  general  form  to  the  backing  by  punching  it  from  a  piece  of  gold 
plate  of  the  required  thickness. 

After  the  backings  have  been  made  fast  to  the  teeth,  they  are  to  be 
accurately  fitted  to  the  plate,  standing  off  from  the  plate  enough  for 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE.        771 

a  very  thin  piece  of  watch  spring  to  be  passed  under  it.  This  shows 
that  the  tooth  is  not  raised,  by  the  backing,  from  its  place  in  the  in- 
vestment. A  much  wider  space  makes  the  flow  of  solder  uncertain  ; 
the  practice  of  placing  scraps  of  gold  under  badly-fitting  backings  is  a 
very  slovenly  one. 

Some  dentists  back  the  teeth  as  they  grind  and  fit  them,  and  before 
investing ;  others  invest  with  the  soldering  mixture,  and  back  without 
taking  them  from  the  investment;  others,  again,  partially  invest  with 
the  soldering  mixture,  remove,  and  back  the  teeth,  then  replace,  and 
add  more  plaster  and  asbestos  or  sand  over  the  edges  of  the  teeth.  By 
the  first  two  methods  neat  or  secure  work  cannot  be  made ;  the  last  is 
unsafe,  because  the  two  layers  of  mortar  are  apt  to  separate  in  heating, 
and  may  displace  the  teeth.  The  most  certain  method,  which  proves 
in  the  end  the  shortest,  is  that  of  the  temporary  plaster  band  above 
described. 

Backings  (called  also  stays  or  standards)  vary  much  in  size,  shape, 
and  thickness.  Some  variations  are  matters  of  taste;  as,  whether  they 
shall  be  rounded,  squai-e,  or  beveled  at  the  top  corners;  whether  cham- 
fered to  a  thin  edge,  or  left  thick,  and  then  beveled  or  rounded.  But 
other  points  often  considered  optional  are  not  so,  inasmuch  as  they 
affect  the  appearance  or  stability  of  the  work.  Backings  which  cover 
the  translucent  edge  of  the  tooth  darken  it  by  the  refraction  of  the 
oxidized  surface  next  the  tooth,  and  which  cannot  be  kept  bright;  even 
if  it  could,  the  gold  would  impart  a  yellowish  tinge.  They  should  cover 
enough  of  the  tooth,  and  fit  so  accurately,  as  to  prevent  motion  of  the 
tooth  ;  for  this  will  inevitably  cause  the  pins,  sooner  or  later,  to  break 
off".  Backings,  in  relation  to  each  other,  must  either  be  so  far  apart  at 
their  base  that  the  solder  will  not  flow  from  one  to  the  other,  forming 
a  continuous  band,  or  they  must  be  in  contact  throughout  whatever 
distance  the  solder  will  unite  them.  This  rule  is  particularly  applic- 
able to  backings  of  single  gum  teeth,  which  are  often  (perhaps  usually) 
made  the  full  width  of  the  tooth  up  to  the  shoulder.  This  continuous 
band  gives  great  stiffness  to  the  plate.  But  the  contraction  of  the 
solder  will  certainly  warp  it,  unless  prevented  by  actual  contact  of  the 
edges  soldered.  In  case  of  plain  teeth,  a  heavy,  continuous  line  of 
solder  will  almost  certainly  warp  the  plate.  A  block  may  be  backed 
for  soldering  in  one  piece,  or  in  parts  closely  fitted,  or  in  distinct  back- 
ings opposite  each  tooth.  A  block  much  curved  is  with  difficulty 
backed  in  one  piece ;  long  or  thin  blocks  are  liable  to  be  cracked  by 
the  contraction  of  a  backing,  either  in  one  piece  or  made  continuous  by 
soldering.  Backings  should  be  of  the  same  gold  as  the  plate,  but 
heavier,  especially  if  long  or  large. 

Sometimes  the  shape  of  a  gum  or  block  tooth  may  require  the  re- 


772 


MECHANICS. 


moval  of  the  plaster  rim,  which  can  readily  be. done;  then  replaced 
after  the  backing  is  completed,  for  the  final  adjustment  of  the  teeth. 
The  teeth  are  next  to  be  fastened  to  the  plate  with  a  small  quantity  of 
cement  (resin  mixed  with  wax,  or,  still  better,  with  gutta-percha  and 
plaster),  and  a  small  roll  of  softened  wax  (not  melted  or  made  adhe- 
sive) placed  over  the  entire  surface  to  be  soldered.     In  Fig.  589  the 

inner  band  may  be  taken  to  represent  the 
width  of  this  wax  roll,  which  is  of  great 
service  in  preventing  any  plaster  of  the 
investment  from  getting  accidentally  upon 
the  pai'ts  to  be  soldered.  If  the  teeth  have 
been  previously  soldered  to  the  backings, 
this  wax  strip  should  be  narrower ;  but  if 
rivets  and  backings  are  to  be  soldered  at 
the  same  time,  the  rim  must  be  made  care- 
fully to  cover  every  point  where  solder  is 
to  flow.  The  plaster  band  is  then  very 
carefully  removed,  and  the  piece  surrounded  with  the  soldering  invest- 
ment, which  must  be  no  thicker  than  is  sufficient  to  protect  the  teeth 
and  hold  them  in  place.  The  wax  and  cement  are  easily  removed, 
leaving  the  surfaces  perfectly  clean  and  ready  for  the  borax  and  solder. 
The  investment  should  not  project  so  far  over  the  inner  edge  of  the 
teeth  as  to  obstruct  the  blowpipe  flame ;  it  should  not  cover  the  lingual 
surface  of  the  plate,  nor  should  it  be  thick  on  the  palatine  surface.  On 
the  palatine  side  it  might  be  well  also  to  cut  along  the  median  line 
nearly  or  quite  through  the  investment ;  the  object  of  this  is  to  give 
play  to  the  lateral  expansion  of  the  plate,  the  antero-posterior  expan- 
sion being  usually,  from  the  shape  of  the  plate,  sufficiently  free.  This 
we  regard  the  simplest  and  best  method  to  prevent  w^arping  of  the  plate, 
so  often  caused  by  the  very  means  taken  to  prevent  it. 

We  have  said  nothing  of  fastening  the  teeth  with  a  firm  body  of 
cement  instead  of  wax,  so  as  to  try  them  in  the  mouth  before  soldering, 
because  a  correctly  taken  articulation  makes  this  unnecessary.  As 
remarked  in  the  chapter  on  articulation,  this  process  admits  of  per- 
fect accuracy.  Its  very  object  is  to  prevent  the  necessity  of  any 
change  in  arrangement  after  teeth  are  adjusted.  An  error  of  articu- 
lation will  often  involve  a  change  in  the  jointing  of  blocks  more 
troublesome  than  the  original  grinding;  in  fact,  neatly  ground  blocks 
(or  gum  teeth)  will  not  permit  the  slightest  change  of  position  without 
fresh  grinding  somewhere.  Trial  of  teeth,  merely  to  test  the  correct- 
ness of  articulation,  is  either  unnecessary,  or  it  is  evidence  of  a  want 
of  skill.  When  used  to  test  correctness  in  the  selection  of  teeth,  it  is 
more  excusable ;  for  it  requires  experience  to  enable  us  to  determine, 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE.        773 

a  priori,  just  what  style  of  work  is  best  adapted  to  the  case.  But  the 
awkward  and  momentary  retention  of  a  plate  to  which  the  teeth  are 
so  slightly  attached,  is  no  test  of  its  aesthetic  correctness,  unless  the 
selection  has  been  grossly  misjudged.  It  is  only  after  the  patient  has 
become  habituated  to  the  piece,  giving  time  for  the  natural  form  of 
the  lips  and  motions  of  the  mouth,  that  we  can  best  decide  whether  or 
not  our  work  has  beauty  of  expression  as  well  as  artistic  finish. 

Mr.  Andrew  Wilson,  of  Scotland,  adopts  the  following  method  of 
backing  teeth  :  After  having  partially  fitted  the  tooth  to  the  plate, 
take  a  piece  of  platina  foil,  as  thick  as  can  be  used  conveniently,  and, 
pressing  it  against  the  tooth,  perforate  it  where  it  is  marked  by  the 
pins  ;  then  cut  it  into  the  required  shape  of  the  backing,  and  press  it 
as  closely  as  possible  to  the  back  of  the  tooth.  Apply  a  little  borax  to 
the  platina  pins  which  come  through  the  back;  then  place  the  tooth, 
with  its  face  downward,  upon  a  thin  piece  of  pumice,  covered  with  dry 
plaster,  putting  upon  the  platina  sufficient  gold  for  the  thickness  re- 
quired ;  slowly  heat  it,  gradually  raising  the  heat  until  the  gold  melts, 
^yhen  it  will  rapidly  flow  over  the  whole  platina  surface,  uniting  so 
firmly  with  the  pins  in  the  tooth,  that  Mr.  W.  has  never,  during  eight 
years'  use,  seen  a  case  in  which  they  have  loosened,  even  where  there 
has  been  sufficient  violence  to  break  the  tooth.  After  the  backing 
has  been  run,  and  the  tooth  allowed  to  cool  slowly,  it  is  filed  to  the 
requisite  thickness  and  shape  ;  tooth  and  backing  are  then  closely  fitted 
and  finally  soldered  to  the  plate.  In  arranging  the  teeth  on  the  plate 
for  soldering,  Mr.  Wilson  uses  a  mortar  of  white  sand  and  plaster, 
equal  parts,  placing  a  thin  strip  of  platina  on  the  outside  of  the  teeth, 
with  a  layer  of  the  mortar  on  both  sides  of  it,  so  that,  should  the 
plaster  crack  in  soldering,  the  platina  may  keep  the  teeth  from  shifting 
their  places.  The  whole  time  occupied  in  heating  and  backing  a  tooth 
is  about  half  an  hour  ;  when  several  are  done  at  once,  a  little  longer 
time  is  required.  Of  course,  all  the  backings  of  the  set  should  be 
flowed  at  the  same  heating. 

Instead  of  using  the  strip  of  platina  plate  to  prevent  the  teeth  from 
becoming  displaced,  in  case  the  plaster  cracks,  thin  sheet  iron  or  iron 
wire  may  be  used  ;  but  platina  is  undoubtedly  the  neatest,  and  has  the 
advantage  of  being  indestructible  ;  it  may  be  narrow  and  thin,  so  that 
its  cost- would  form  no  objection  to  its  use.  But  if  the  plaster  is  not  in 
excess,  the  investment  will  not  crack.  A  mortar,  made  of  three  or 
four  parts  of  asbestos  to  one  of  plaster,  will  stand  the  hottest  fire  of  the 
laboratory.  Mr.  Wilson's  method  might  be  improved,  first,  by  com- 
pletely fitting  the  tooth  before  backing ;  secondly,  by  running  the  thin 
platina  backing,  one-sixteenth  of  an  inch  on  the  plate,  to  any  irregu- 
larities of  which  it  can  be  quickly  burnished  down  by  making  several 


774 


MECHANICS. 


slits  in  the  edge.  This  flange  secures  a  very  perfect  and  strong  attach- 
ment to  the  plate,  and  is  the  method  of  backing  (with  heavier  platina) 
practiced  in  the  continuous-gum  work. 

Ordinary  backings,  after  they  have  been  fitted  to  the  plate  and  held 
to  the  teeth  by  bending  or  splitting  the  pins,  may  be  removed  from  the 
plate,  set  in  a  batter  of  plaster  (with  or  without  asbestos),  and  soldered  ; 
the  plaster  should  be  so  stiff  as  not  to  flow  over  the  backings.  The 
solder  should  be  rather  harder  to  fuse  than  that  used  to  fasten  the 
teeth  to  the  plate.  The  backings,  after  slowly  cooling,  should  be  filed, 
and  may  even  be  Scotch-stoned.     Backings  can  be  better  and  more 

Fig.  590. 


quickly  finished  singly  than  when  attached  to  the  plate.  This  method, 
or  Mr.  "Wilson's,  are  much  to  be  preferred  to  the  common  practice  of 
soldering  the  backings  to  both  teeth  and  plate  at  the  same  heating. 

A  piece  invested  preparatory  for  soldering,  and  placed  upon  a  lump 
of  solid  charcoal,  is  seen  in  Fig.  590. 

Directions  for  applying  boras  and  solder  have  already  been  given. 
Some  cut  the  solder  into  very  small  pieces  ;  others  use  one  piece  to  each 
tooth  at  its  base,  and  a  second  for  the  pins  unless  previously  soldered ; 
in  the  figure  the  pieces  are  unnecessarily  small.     If  the  backings  are 


ADJUSTMENT  OF  TEETH  TO  THE  PLATE. 


775 


soldered  to  the  teeth  beforehand,  a  more  fusible  grade  of  solder  should 
be  used  at  the  second  soldering.  The  work,  as  before  stated,  must  be 
very  gradually  and  thoroughly  heated  up,  before  directing  the  flame 
upon  the  plate  or  backings.  The  last  point  to  be  touched  with  the 
flame  is  the  solder,  and  this  not  before  a  slight  melting  of  the  edge 
shows  that  it  is  just  on  the  point  of  flowing.  If  every  preparation  for 
soldering  has  been  properly  made,  the  actual  flowing  of  the  solder  on 
a  full  piece  will  take  less  than  a  minute,  and  will  be  so  smooth  as  to 
require  no  other  finish  than  the  Scotch  stone  and  the  polishing  wheels. 
After  soldering,  the  cover  should  be  placed  upon  the  soldering  pan 
(Fig.  571),  and  the  work  allowed  to  become  quite  cold  before  removal ; 
when  a  charcoal  lump  (Fig.  590)  or  pumice  stone  is  used  the  work 
must  also  be  covered  while  cooling. 

Finishing  Process. — When  the  piece  is  cold,  the  plaster  is  to  be  care- 
fully removed  from  the  teeth ;  the  piece  is  then  placed  in  a  glass  or 


Fig.  591. 


porcelain  vessel  containing  a  mixture  of  equal  parts  of  sulphuric  acid 
and  water,  and  heat  applied.  As  soon  as  the  borax  (which,  by  the 
process  of  soldering,  has  lost  its  water  of  crystallization  and  assumed 
a  glassy  hardness)  is  decomposed,  the  vessel  is  removed  and  allowed 
slowly  to  cool.  This  process  is  termed,  by  jewelers,  pickling,  and 
requires  from  ten  minutes  to  half  an  hour  for  its  completion,  according 
to  the  strength  of  the  acid  and  the  quantity  of  vitrified  borax  on  the 
plate.  After  this  the  acid  is  washed  from  the  piece ;  or  it  is  still  n)ore 
eflTectually  deprived  of  acid  by  boiling  in  water  containing  a  little 
caustic  soda. 

In  removing  the  roughness  which  may  have  been  occasioned  by 
imperfect  soldering,  care  must  be  taken  not  to  cut  away  too  much  of 
the  plate.  For  this  purpose  scrapers,  files,  and  lathe  burrs  are  used, 
according  to  the  position  and  quantity  of  surplus  solder.  Fig.  591 
represents  a  set  of  solder  burrs  for  trimming  ofi"  superfluous  solder. 


776 


MECHANICS. 


After  the  work  has  been  made  as  smooth  as  possible  with  scrapers, 
etc.,  it  should  be  rubbed  with  pieces  of  Scotch  stone  and  water  until 
every  scratch  is  removed  ;  some  use  a  fine,  smooth  cork  attached  to  the 
lathe,  and  charged  with  water  and  powdered  pumice  or  silex.  The 
piece  is  then  polished  with  Tripoli,  applied  by  means  of  oil  or  tallow  to 
a  brush  wheel  (Fig.  595),  which  is  made  to  revolve  rapidly  against  the 
work.  Felt,  rubber,  walrus  leather  and  cotton  wheels  and  cones  are 
also  employed  in  polishing.  Fig.  592  represents  a  felt  wheel  and  cone. 
Fig.  593  shows  one  of  the  various  forms  of  vulcanite  burrs  for 
carrying  polishing  powders.  As  to  the  rapidity  with  which  a  lathe 
should  be  worked :  drills  and  burrs  require  a  slow  movement ; 
corundum  wheels  a  quicker  one ;  rotten  stone  a  rapid  motion  ;  and 
whiting,  zinc-white,  or  rouge,  the  most  rapid  of  all. 


Fig.  592. 


Fig.  593. 


The  piece  may  now  be  placed  in  a  porcelain  vessel  containing  the 
following  mixture :  nitre,  two  ounces,  salt  and  alum,  each  one  ounce — 
dissolved  in  four  ounces  of  water.  After  boiling  for  half  an  hour  in 
this,  to  decompose  the  copper  from  the  surface  layer  of  the  solder  and 
plate,  it  is  boiled  a  few  minutes  in  a  solution  of  one  ounce  of  caustic 
soda  in  four  ounces  of  water,  to  neutralize  the  acid,  then  washed  with 
a  brush  in  pure  water. 

The  removal  of  the  copper  from  the  surface  of  the  plate  gives  to  the 
gold  the  beautiful  orange  hue,  which  is  its  natural  color,  and  which  it 
will  retain  until  the  friction  of  mastication  wears  oiF  this  surface.  The 
secretions  of  the  mouth  will  fail  to  tarnish  it ;  and  it  will  be  free  from 
the  disagreeable  taste  of  which  so  many  complain  who  wear  artificial 


ADJUSTMENT   OF   TEETH   TO   THE   PLATE, 


777 


teeth  set  on  metallic  plate.  But 
when  plate  is  made  from  coin 
without  alloy,  or  is  of  twenty 
carats  fineness,  and  the  solder 
has  a  corresponding  quality, 
the  pickling  process  may  be 
omitted. 

The  process  of  finishing  is 
completed  by  polishing  every 
part  of  the  lingual  surface  of 
the  plate,  backings,  and  clasps 
with  highly  tempered  and  finely 
polished  steel  burnishers.  Fig. 
594  represents  various  forms  of 
plate  burnishers.  They  should 
be  frequently  rubbed  on  a  piece 
of  wet  Castile  soap,  and  carried 
backward  and  forward  in  the 
same  direction  over  the  plate 
until  every  part  of  the  gold 
exhibits  a  high  polish.  Bur- 
nishers of  difierent  shapes  are 
required  for  different  parts  of 
the  work ;  bloodstone  bur- 
nishers are  also  used. 

A  piece,  Jiowever,  can  be 
polished  in  less  time,  if  not 
more  perfectly,  with  brush 
wheels  (Fig.  595).  Brush 
wheels  vary  in  diameter,  thick- 
ness, and  material.  Bristle 
wheels  vary  in  stiffness  and 
length  of  bristle ;  the  stiffer 
being  used  for  Tripoli  or  rotten 
stone,  the  softer  for  whiting  and 
rouge.  Cotton  is  often  substi- 
tuted for  bristles  ;  buckskin  or 
felt  are  also  much  used  for 
wheels  or  circular  "  laps,"  and 
are  especially  useful  in  dressing 
up  the  recesses  of  a  plate.  It 
is  of  the  utmost  importance 
that  wheels   or  laps    used  for 


Fig.  594. 


Fig.  595. 


778  MECHANICS. 

different  polishing  substances  should  be  kept  entirely  separate  ;  a 
little  Tripoli  or  pumice  powder  on  a  rouge  wheel  may  render  useless 
the  work  of  an  hour.  The  brush  should  be  set  on  the  spindle  of  the 
lathe,  then  lightly  smeared  with  suet,  by  holding  a  small  piece  against 
it  while  it  is  revolving.  The  rotten  stone  is  applied  in  the  same 
manner,  and  with  the  brush  thus  charged,  the  polishing  may  com- 
mence ;  but  the  plate  must  not  be  exposed  too  long  to  the  friction,  as 
it  will  rapidly  wear  away  the  pure  gold  surface  brought  out  by  the 
pickle  ;  hence  some  use  only  the  burnisher  or  rouge  after  pickling. 
Tripoli  has  a  sharper  grit,  and  cuts  more  rapidly  than  the  ordinary 
rotten  stone  prepared  for  daguerreotypists'  use  ;  but  the  latter  gives  a 
very  smooth  surface,  and  will,  in  most  cases,  give  a  sufficiently  brilliant 
finish  without  rouge.  A  very  high  watch-case  finish  can  only  be 
given  by  very  rapid  revolution  of  wheels  or  buflfers,  charged  with  the 
finest  quality  of  rouge,  wet  with  alcohol.  The  piece  must  be  previously 
washed  with  soap  and  water,  so  as  to  remove  every  trace  of  oil. 
Sometimes  rouge  is  applied  on  a  piece  of  soft  buckskin,  wrapped  or 
sewed  around  small,  blunt-pointed  pieces  of  cork  or  wood.  The  lingual 
surface  of  the  plate  is  the  only  one  that  should  be  polished.  The  dead 
color  of  the  palatine  surface  throws  out  the  polish  of  the  other  side, 
and  greatly  improves  the  appearance  of  the  piece.  The  adhesion  of  a 
plate  is  frequently  improved  by  roughening  the  plate  with  a  file  or  by 
engraving  lines  upon  it.  The  process  of  finishing  on  a  gold  piece, 
properly  soldered,  is  a  very  simple  matter,  and  one  of  secondary 
importance.  A  piece  with  a  Scotch-stone  finish  is  in  every  respect  as 
useful,  and  aesthetically  as  beautiful,  as  the  most  highly  polished  plate. 
There  is,  however,  no  objection  to  this  sort  of  appeal  to  the  eye,  pro- 
vided it  is  not  the  chief  merit  of  the  work. 

There  are  three  methods  adopted  for  the  retention  of  dental  plates, 
and  many  modifications  of  form  required  by  the  various  circumstances 
of  different  mouths.  An  enumeration  of  all  the  required  forms  would 
be  impossible  in  this  work ;  but  we  hope  to  represent  a  sufficient 
variety  to  enable  the  operator  to  decide  which  is  best  for  any  given 
case.  We  think  it  far  more  important,  however,  to  endeavor  to 
explain,  as  far  as  can  be  done,  the  principles  which  determine  these 
different  forms  and  modes  of  retention,  than  to  lay  down  any  set  of 
didactic  formulas  for  unreasoning  adoption. 


RETENTION   OF   BASE   PLATES. 


779 


CHAPTER  XIII. 


RETENTION   OF   BASE   PLATES — THEIR  SIZE  AND    FORM    OF    OUTLINE. 


Fig.  596. 


THE  utility  of  a  piece  depends  largely  upon  the  firmness  with  which 
it  keeps  its  place  during  mastication  or  in  conversation.  The 
means  adopted  to  secure  this  are  fourfold  :  The  first  two  retain  the 
plate  by  extrinsic  support ;  the  last  two  depend  upon  an  intrinsic 
quality  of  the  plate  itself.  1.  Spiral  springs,  by  constant  pressure, 
keep  the  plates  of  a  double  set  in  position.  2.  Clasps,  by  grasping 
some  natural  tooth,  hold  a  partial  piece  firmly  in  place.  3.  Spring 
plates,  which  are  constructed  of  vulcanized  rubber,  and  are  available 
only  in  partial  cases.  4.  The  close  adaptation  of  the  plate,  whether  of 
a  full  or  partial  set,  causes  it  to  adhere  with  a  force  which  is  lessened, 
first,  by  the  amount  of  air  between 
the  surfaces ;  secondly,  by  the  lia- 
bility to  displacement.  These  modes 
of  retention  will  be  considered  in 
the  order  named. 

Spiral  springs,  formerly  very  much 
used,  are  now  seldom  employed ; 
they  are  applied  only  to  double 
dentures.  Fig.  596  gives  a  correct 
idea  of  the  position  of  the  springs, 
their  points  of  attachment,  length, 
and  direction  of  curvature.  Fig.  597 
represents  the  detached  portions  of  the  spring,  consisting  of  standards, 
screws,  tangs,  and  spiral  coil.     The  tendency  of  the  curved  spring  to 


Fig.  597. 


fM/iMf/iMmMiMrimMm:mm/Mmmmmm 


straighten,  presses  each  plate  upon  the  alveolus,  acting  at  the  points  of 
attachment  of  the  standards.  These  points  are  chosen,  first,  in  the 
upper  jaw,  as  nearly  as  possible  on  the  line  of  equipoise,  which  will  be 


780  MECHANICS. 

somewhere  between  the  centres  of  the  second  bicuspid  and  of  the  first 
molar  ;  secondly,  in  the  lower  jaw,  where  a  vertical  line  from  the  upper 
standard  meets  it.  Perforated  bicuspids  and  molars  are  sold,  adapted 
to  such  cases  ;  and  the  usual  plan  is  to  attach  the  standards  before 
soldering  the  teeth.  A  more  accurate  method  is  to  determine  the 
position  of  the  standards  after  the  pieces  are  finished.  The  presence  of 
the  teeth  makes  soldering  of  the  standards  more  troublesome,  but  not 
impossible ;  they  may  also  be  riveted  to  the  outer  rim  of  the  plate. 
With  the  diamond  drill,  holes  can  be  made  through  the  teeth,  or 
blocks,  opposite  each  standard. 

Directions  for  making  the  coil  have  already  been  given  ;  they  are 
usually  purchased  ready  made.  Their  length  must  be  such  that  the 
curve  will  not  irritate  the  ascending  ramus  of  the  lower  jaw.  If  too 
stiff,  their  forcible  pressure  will  irritate  the  gum  ;  if  too  slight,  they 
will  fail  to  keep  up  the  piece.  The  tangs  are  held  in  the  coil  by  close- 
ness of  fit ;  when  loose,  they  may  be  tightened  by  floss  silk.  The 
screws,  represented  in  the  figure,  are  troublesome  to  make,  and  are  very 
apt  to  loosen.  A  better  plan  is,  to  pass  a  headed  pin  through  standard, 
tang  and  tooth,  and  rivet  or  solder  it  in  the  backing.  This  plan 
makes  the  tang  permanent ;  the  pieces  are  separated  by  detaching  the 
upper  or  lower  tangs  from  the  coils.  It  adds  greatly  to  the  strength 
of  the  pin  to  pass  it  through  the  tooth  or  block.  There  should  also  be 
a  shoulder  on  the  standards,  to  limit  the  movement  of  the  tang ;  else 
the  springs,  by  too  great  upward  or  downward  motion,  may  irritate 
the  mouth.  It  is  unnecessary,  in  view  of  the  present  limited  use  of 
springs,  to  describe  other  and  very  ingenious  methods  of  attaching 
them. 

Their  use  is  now  confined,  first,  to  very  flatly-arched  upper  jaws, 
usually  small,  covered  with  hard  membrane,  and  having  the  attach- 
ment of  the  facial  muscles  close  to,  or  quite  upon,  the  ridge ;  also  to 
lower  cases,  where  all  trace  of  the  ridge  is  gone.  Secondly,  to  pieces 
inserted  so  soon  after  extraction  that  the  rapid  absorption  will  quickly 
destroy  the  adaptation.  We  shall  speak  elsewhere  of  other  means 
adopted  to  meet  these  exigencies ;  in  failure  of  which,  spiral  springs 
are  to  be  used.  But  they  are  troublesome  to  make,  annoying  to  wear, 
difficult  to  keep  clean  and  liable  to  accident ;  hence  we  only  use  them 
as  a  last  resort.  In  conclusion,  it  should  be  noticed  that  the  upper 
plate  of  spiral-spring  pieces  does  not  cover  the  palate,  but  is  shaped 
more  like  the  lower  piece.  This  is  one  of  its  compensating  ad- 
vantages ;  for  it  is  an  objection  to  the  otherwise  valuable  principle  of 
atmospheric  pressure  that  it  covers  so  large  a  portion  of  the  mucous 
surface. 


RETENTION   OF   BASE   PLATES.  781 

CLASPS. 

This  method  of  retention,  necessarily  applicable  only  to  partial 
pieces,  has  fallen  into  much  disfavor,  and  given  place  to  methods,  in  lieu 
thereof,  which  are  really  more  objectionable.  But,  like  many  other 
time-honored  practices  which  modern  dentistry  has  thrown  in  its  waste 
basket,  there  are  very  decided  advantages  in  this  mode  of  retention, 
which  make  it,  in  certain  cases,  the  best  possible  one.  The  disuse  of 
clasps  has  grown  out  of,  first,  their  injurious  effects,  due  to  improper 
construction  and  injudicious  application  ;  secondly,  the  diflBculties  of 
making  a  clasp  piece.  We  venture  the  assertion,  that  one-half  the 
dentists  do  not  really  know  how  to  make  a  perfectly  adapted  clasp 
piece ;  and  that,  of  the  remaining  half,  two-thirds  will  not  take  the 
trouble.  The  tediousness  of  clasp  adjustment  is  out  of  place  in  that 
rapidity  of  manipulation  demanded  by  the  cheapness  of  modern  den- 
tistry. Nor  can  we  expect  to  see  the  easily  made,  but  ineffectual, 
vacuum  cavity  give  place,  in  turn,  to  the  clasp  attachment,  which  it  has 
to  such  an  extent  superseded,  until  the  profession  becomes  awakened  to 
the  necessity  of  substituting  good  work  for  fast  work — economical 
high-priced  work  for  expensive  low-priced  work ;  until  the  mechanician 
so  far  respects  himself  as  to  value  his  labor  more  than  the  cost  of  his 
materials,  and  ceases  to  use  certain  substances  because  they  are  cheap, 
rather  than  others  because  they  are  better. 

Next  to  pivoting,  the  clasp  is  the  most  secure  of  all  methods  of 
attaching  artificial  teeth  in  partial  cases.  But  it  is  not  universally 
applicable,  for  reasons  hereafter  stated.  In  deciding  upon  the  propriety 
of  using  clasps,  the  remaining  teeth  must  be  carefully  examined,  to 
determine  whether,  in  shape,  position,  texture  and  relation  to  other 
teeth  and  to  the  proposed  plates,  there  are  any  which  admit  of  being 
clasped.  If  there  are  such  teeth,  a  perfect  impression  of  them  is 
necessary ;  then  greatest  accuracy  in  fitting  the  clasp  ;  lastly,  a  most 
exact  adjustroent  of  this  to  the  plate,  to  which  it  is  to  be  fastened  with 
great  care.  Scrupulous  observance  of  these  points,  in  connection  with 
a  properly  fitted  and  shaped  plate,  will  take  from  clasp  work  the  force 
of  the  objections  urged  against  it. 

In  the  selection  of  teeth  to  be  clasped,  the  points  for  consideration 
are:  1.  Their  condition:  never  clasp  loose  teeth,  or  those  where  there 
is  much  alveolar  absorption ;  or,  if  possible  to  avoid  it,  those  which 
have  filed  surfaces.  2.  Their  shape :  avoid  all  conical  teeth,  such  as 
third  molars  and  canines ;  also  teeth  considerably  larger  at  the  grind- 
ing surface  than  at  the  gum.  The  proper  shape  for  clasping  is  the 
cylinder,  or  rounded  prism ;  and  only  so  much,  or  such  part,  of  any 
tooth  should  be  clasped  as  has  this  shape.  Hence  it  is  that  thick, 
narrow  clasps  are  best,  because  few  teeth  have  much  breadth  of  cylin- 


782  MECHANICS. 

drical  shape.  3.  Their  position :  incisors,  canines  and  third  molars 
must  be  rejected,  for  this  reason  ;  and  second  molars  are  unfit,  if  the 
plate  holds  incisor  teeth.  The  incisors  and  cuspids  are,  of  all  the 
teeth,  least  suited  for  the  attachment  of  a  clasp.  It  is  exceedingly 
diflScult  to  apply  clasps  to  these  teeth  in  such  a  manner  as  to  retain 
even  a  single  tooth  with  suflicient  stability  to  be  worn  with  any  degree 
of  comfort.  We  remember  once  to  have  seen  a  case  in  which  a  central 
incisor  (natural  tooth)  was  inserted  and  kept  in  place  by  a  gold  wire 
projecting  from  each  side  of  the  tooth  into  holes  drilled  into  the  adjoin- 
ing teeth.  A  stage  of  dental  progress  that  permitted  such  a  process, 
might  also  have  allowed  the  clasping  of  incisors ;  but  we  know  of  no 
possible  circumstances  that  will  justify,  in  the  present  state  of  dental 
art,  the  clasping  of  any  of  the  six  front  teeth.  No  lower  teeth  should 
be  clasped  ;  but  in  some  cases  a  stay  (half-clasp)  may  be  used.  The  best 
teeth,  in  respect  of  position,  are  the  second  bicuspids;  next,  the  first 
molars;  thirdly,  the  first  bicuspids;  and  lastly,  the  second  molars. 
These  eight  teeth  are  the  only  ones  that  should  ever  be  clasped  ;  and, 
if  possible,  the  choice  should  be  confined  to  the  first  four.  4.  Their 
relation  to  the  plate  and  to  the  other  teeth.  Let  the  clasped  tooth  be 
as  near  the  line  of  equipose  as  is  consistent  with  other  considerations. 
For  incisors  alone  we  should,  for  this  reason,  give  preference  to  the 
first  over  the  second  bicuspids;  and,  in  case  of  the  loss  of  the  ten  or 
twelve  anterior  teeth,  we  should  use  no  clasp  on  the  remaining  molars. 
Teeth  not  decayed  should  never  be  separated  from  others  with  which 
they  are  in  contact,  for  the  purpose  of  passing  a  clasp.  If  no  other 
tooth  can  be  found,  a  stay  (half-clasp)  must  suffice. 

Observance  of  the  conditions  above  enumerated  restrict  very  much 
the  range  of  cases  that  admit  of  clasps.  In  the  matter  of  position 
and  relation  to  the  plate,  circumstances  may  compel  a  choice  not  the 
most  favorable  to  success;  but  in  other  respects  it  is  far  better  to  dis- 
pense with  clasps  than  to  apply  them  so  as  to  incur  risk  of  failure  or 
injury  to  good  teeth. 

The  liability  to  decay,  of  the  tooth  around  which  a  clasp  is  applied, 
is  always  greatly  increased  by  the  removal  of  any  portion  of  its  enamel. 
The  application  of  clasps  to  diseased  or  loose  teeth  always  aggravates 
the  morbid  condition  of  the  parts,  and  causes  the  substitute,  which 
they  keep  in  place,  to  become  a  sort  of  annoyance  to  the  patient.  Be- 
sides, such  teeth  can  be  retained  in  the  mouth  only  for  a  short  time, 
and  when  they  give  way,  the  artificial  appliance  becomes  compara- 
tively or  entirely  useless ;  and  even  before  their  loss,  it  is  not  held 
firmly  in  its  place.  Its  instability  exposes  its  presence  to  the  observa- 
tion of  the  most  careless  observer,  and  this  motion  is  injurious  to  all 
the  teeth  near  or  against  which  the  piece  comes.     In  the  lower  jaw, 


RETENTION   OF   BASE   PLATES.  783 

parts  of  sets  are  much  less  frequently  called  for  than  in  the  upper,  and 
when  they  are,  the  use  of  clasps  may  be  dispensed  with  altogether.  A 
clasp  can  seldom  be  applied  advantageously  to  a  lower  molar.  The 
lower  front  teeth  are  least  liable  to  decay  of  any  in  the  mouth,  and 
therefore  do*  not  require  replacement,  except  in  full  sets,  unless  lost  by 
a  blow  or  by  the  destructive  action  of  salivary  calculus.  A  partial 
lower  front  piece  calls  for  half-clasps  or  stays ;  but  other  partial  lower 
pieces  (replacing  bicuspids  and  molars)  should  not  depend  for  their 
stability  upon  any  remaining  bicuspid  or  cuspid. 

If  the  injurious  effects  liable  to  result  from  the  application  of  clasps 
to  teeth  selected  according  to  the  rules  given  could  uot  in  any  way  be 
counteracted,  dental  substitutes  retained  in  the  mouth  by  this  means 
would,  in  the  majority  of  cases,  be  productive  of  more  injury  than 
benefit ;  but  they  may  be  in  great  measure  prevented.  They  are  not 
caused,  as  many  have  erroneously  supposed,  solely  by  the  mechanical 
action  of  the  clasps  upon  the  teeth,  but  also  by  the  chemical  action  of 
the  secretions  of  the  mouth  and  decomposing  particles  of  food.  The 
method  of  measurably  preventing  these  deleterious  effects  is  twofold  : 
First,  to  prevent  the  chemical  action,  the  removal  of  the  artificial  teeth, 
and  thorough  cleansing  of  them  and  the  natural  organs  ;  this  should 
be  done  every  night  and  morning,  and  the  teeth  rubbed  with  a  brush 
arid  waxed  floss  silk  until  every  particle  of  clammy,  vitiated  mucus 
and  foreign  matter  is  removed.  The  inner  surface  of  the  clasps  should 
be  freed  from  all  impurities,  and  the  whole  piece  cleansed  with  a  brush 
and  water.  Secondly,  to  prevent  or  lessen  the  mechanical  action,  the 
clasp  should,  as  before  remarked,  fit  with  great  accuracy  the  parts  of 
the  tooth  protected  with  hard  enamel ;  the  whole  piece  should  have 
such  closeness  of  adaptation  as  to  prevent  motion  of  the  clasp  upon  the 
tooth.  We  have  elsewhere  spoken  of  other  injurious  consequences  of 
clasps  placed  too  near  the  gums  or  exposed  necks.  Rapid  decay  and 
breaking  oflf  of  the  teeth,  inflammation  of  the  gums,  of  the  alveolo- 
dental  periosteum,  destruction  of  the  alveoli  and  loosening  of  the  teeth, 
are  among  the  common  results  of  the  clasping  of  teeth  as  it  is  too  often 
practiced.  Consequences  such  as  these  have  led  many  to  an  unquali- 
fied condemnation  of  this  method ;  yet,  as  we  have  said,  when  suitable 
teeth  are  selected  for  clasping,  and  the  work  is  properly  executed,  it 
is  the  best  and  most  durable  way  in  which  a  partial  piece  can  be 
secured. 

Shaping  and  Adjusting  Clasps. — The  gold  employed  for  clasps  should 
be  about  one-third  or  one-half  thicker  than  the  plate,  and  as  wide 
as  the  cylindrical  portion  of  the  crowns  of  the  teeth  to  be  fitted.  Some 
clasps  are  best  made  of  half-round  wire,  and  narrow  ;  others  may  be 
broader  and  thinner ;  thick,  narrow  clasps  are  more  universally  appli- 


784 


MECHANICS. 


cable.  In  quality  it  is  better  that  clasp  and  plate  be  the  same  ;  except 
when  the  plate  is  of  pure  coin.  In  this  case,  add  copper  (but  no 
silver),  to  give  elasticity.  Platina,  often  used  for  this  purpose,  imparts 
too  much  brittleness,  after  the  piece  has  been  worn  for  some  time. 
Some  may  fit  the  tooth  close  to  the  gum  ;  but  in  other  cases,  the  shape 
of  the  tooth,  absorption  of  the  alveolus,  or  morbid  sensitiveness  of  the 
neck,  forbid  this.  Enamel  surfaces  best  resist  the  wearing  action  of 
clasps  ;  dentine,  exposed  by  the  file  or  chisel,  is  more  liable  to  abrasion 
or  decay ;  ceraentum  should  in  no  case  be  brought  in  contact  with 
clasp  or  plate.  If  the  clasps  chafe  against  sensitive  parts,  inflammation 
of  the  alveolo-dental  membrane  may  be  set  up,  followed  by  wasting  of 
their  sockets,  and  ultimate  loss  of  the  teeth.  Fig.  598  represents  a 
clasp  bender. 

With  the  plate  in  position  in  the  mouth,  a  wax  impression  may  be 
taken ;  the  plate,  adhering  to  it,  on  being  withdrawn,  will  have  a  cor- 
rect relation  to  the  teeth  which  are  to  be  clasped.  Others  adopt  the 
less  accurate  method  of  adjusting  the  plate  to  the  original  plaster 
model.     But  as,  for  reasons  before  given,  it  is  advisable  to  cut  off  the 

E'iG.  598. 


teeth  from  the  model  used  in  moulding,  a  second  model  is  necessary, 
and  usually  for  this  purpose  a  second  impression.  Moreover,  if  the 
mouth  has  marked  irregularities,  or  rugfe,  and  the  plate  covers  much 
surface,  it  cannot  be  fitted  upon  a  plaster  model  so  as  to  hold  the  same 
precise  relation  to  the  teeth  as  when  in  the  mouth. 

When  accurately  fitted,  they  may  be  at  once  soldered  on  the  model, 
or  may  be  attached  to  the  plate  by  means  of  a  small  piece  of  wax  or 
cement  composed  of  one  part  wax  and  two  of  resin,  softened  modeling 
composition  ;  this  should  be  softened,  and  applied  to  the  plate  and  to 
the  inner  side  of  each  clasp.  The  plate  and  clasps  thus  united  are 
carefully  removed  from  the  plaster  model,  and  laid,  with  the  convex 
side  downward,  on  a  piece  of  paper.  Plaster  is  then  poured  on  the 
upper  side  of  the  plate,  covering  it  and  the  clasps  to  the  thickness  of 
half  an  inch.  After  this  has  set,  the  piece  may  be  taken  from  the 
paper,  placed  on  charcoal,  the  wax  being  softened  and  removed,  and 
prepared  for  soldering. 

This  is  the  simplest  way  of  fitting  clasps  to  the  plate  and  preparing 


RETENTION  OF  BASE  PLATES. 


785 


the  piece  for  soldering ;  but  when  the  clasp  teeth  deviate  from  a  verti- 
cal position,  or  when  the  teeth  are  of  such  a  shape  that  the  wax  im- 
pression does  not  copy  them  accurately,  this  method  is,  in  such  cases, 
not  reliable.  The  clasps  must  be  fitted  to  the  teeth  in  the  mouth, 
instead  of  on  the  plaster  model,  and  may  then  be  attached  to  the  plate 
as  just  directed.  Often  only  one  can  be  attached  at  a  time,  and  after 
this  has  been  soldered,  the  piece  is  replaced  in  the  mouth,  and 
the  other  made  fast  to  the  plate.  The  greatest  care  is  necessary  to 
prevent  altering  the  position  of  the  clasp  in  taking  the  piece  from  the 
mouth. 

The  following  is  Dr.  Fogle's  method  for  securing  accurate  adaptation 
of  the  clasps.  They  are  first  fitted  to  the  plaster  model,  leaving  the 
ends  straight.  A  narrow  strip  of  plate,  about  five-eighths  of  an  inch 
in  length,  is  used  as  a  temporary  fastening,  one  end  of  which  is  sol- 
dered to  the  lingual  surface  of  the  clasp ;  the  plate  and  clasp  are  now 


Fig.  599. 


Fig.  600. 


both  placed  on  the  model  (made  from  impression  taken  while  the  plate 
is  in  the  mouth),  and  the  other  end  fitted  and  soldered  to  the  plate, 
forming  a  sort  of  semicircle  or  bow.  Fig.  599  represents  the  plate, 
clasps  and  temporary  fastenings  on  the  plaster  model.  In  Fig.  600, 
they  are  seen  separate  from  the  model. 

The  clasps  are*how  adjusted  to  the  model;  however  accurately  this 
is  done,  it  will  be  found,  on  applying  the  plate  to  the  mouth,  that  they 
will  not  fit  the  teeth  there.  After  properly  adjusting  them,  the  tem- 
porary fastenings  will  be  found  sufficient  to  hold  the  clasps  in  their 
exact  position  while  the  piece  is  being  removed.  This  done,  it  may  be 
invested  in  plaster,  placed  on  charcoal  and  the  other  steps  connected 
with  the  process  of  permanent  soldering  gone  through  with ;  detach- 
ing the  temporary  fastenings  when  the  plaster  has  fixed  the  clasps  in 
position. 

Dr.  Cushman  advises,  in  very  difficult  cases  of  adjustment,  as  where 
50 


786  MECHANICS. 

the  clasp  teeth  are  much  inclined,  and  where  you  have  to  fasten  to 
second  molars,  a  slight  modification  of  this  plan.  After  soldering  one 
end  of  the  strip  to  the  clasp,  and  having  bent  the  other  to  touch  the 
plate  when  on  the  model,  put  both  in  their  proper  place  in  the  mouth; 
then,  with  a  sharp-pointed  instrument,  indicate  the  point  where  the  bow 
touches  the  plate;  place  them  on  the  model  again;  adjust  the  end  of 
the  bow  to  the  point  marked  ;  confine  it  there  and  solder  fast.  Dr. 
Cushman  considers  Dr.  Fogle's  method  of  adjusting  clasps  so  valuable 
that  he  never  ventures  to  set  clasps  permanently,  even  in  the  simplest 
case,  upon  the  original  model,  with  the  plaster  teeth  as  the  only  guide 
for  position. 

Dr.  Lester  Noble's  method  is  as  follows  :  Place  the  plate  in  the 
mouth,  and  let  the  clasp  bind  upon  the  tooth  with  only  sufficient  firm- 
ness to  keep  it  in  its  proper  place.  Then  mix  a  small  quantity  of  plas- 
ter from  a  lot  which,  by  previous  trial,  you  find*  requires  four  or  five 
minutes  to  set ;  put  it  upon  a  piece  of  paper  or  sheet  lead  about  an  inch 
square,  and  just  before  it  begins  to  harden,  introduce  it  into  the  mouth 
upon  the  forefinger,  pressing  it  into  gentle  contact  with  a  portion  of 
the  plate  and  about  one-half  of  the  clasp.  It  must  be  held  there  for 
three  or  four  minutes,  until  it  is  sufficiently  hard  to  break  with  a  sharp 
fracture ;  this  point  you  can  determine  by  examining  the  plaster  left 
in  your  bowl.  The  plaster  must  then  be  withdrawn.  Sometimes  plate, 
clasp  and  plaster  will  be  brought  away  together  ;  or  the  plaster  and 
clasp  together  leaving  the  plate ;  or  the  plaster  will  separate,  leaving 
both  clasp  and  plate  in  the  mouth.  Should  the  plaster  by  any  acci- 
dent break,  it  can  readily  be  united  at  the  point  of  the  fracture,  with- 
out in  the  least  altering  its  shape — one  great  advantage  over  wax.  If 
the  plaster  adheres  to  the  plate  on  withdrawal  from  the  mouth,  it  must 
then  be  carefully  detached,  the  plate  replaced,  and  the  same  process 
repeated  for  the  second  clasp ;  or  possibly  the  impressions  for  both 
clasps  can  be  taken  at  once. 

Several  precautions  are  necessary.  If  the  clasp  bind  too  tightly 
around  the  tooth,  its  ends  will,  when  removed,  spring  together ;  and 
thus  it  will  not  exactly  fill  the  original  impression  made  in  the  plaster. 
If  the  part  of  the  clasp  which  you  design  to  cover  with  plaster  be  so 
regular  in  shape  as  to  make  its  adjustment  -svhen  out  of  the  mouth 
uncertain,  mark  it  with  a  file  or  by  a  small  point  of  solder ;  this  will 
be  copied  in  the  plaster,  and  remove  all  doubt  as  to  its  definite  posi- 
tion. If  the  plaster  be  extended  over  some  part  of  the  edge  of  the 
plate,  it  will,  in  the  absence  of  any  marked  irregularities  of  surface, 
give  a  better  guide  for  its  readaptation.  Lastly,  if  the  plaster  cover 
too  much  of  the  clasp  tooth,  it  will  be  more  liable  to  break  on  being 
withdrawn. 


RETENTION  OP  BASE  PLATES.  787 

Take  now  the  clasps,  place  them  each  in  their  separate  impressions 
in  the  pieces  of  plaster,  securing  them,  if  necessary,  by  a  small  piece 
of  softened  wax.  Place  one  end  of  your  plate  in  its  corresponding 
bed  in  one  of  the  plaster  pieces.  If  proper  care  has  been  used,  both 
clasp  and  plate  will  fit  into  the  plaster  with  unerring  accuracy,  and,  of 
course,  hold  the  precise  relation  as  when  in  the  mouth.  While  in  this 
position,  cover  the  clasp  and  the  under  surface  of  the  plate  with  fresh 
plaster,  or  plaster  and  sand ;  when  this  has  hardened,  remove  the  first 
plaster,  just  as  in  other  cases  you  would  remove  the  wax,  preparatory 
to  soldering. 

The  methods  of  Drs.  Fogle  and  Noble  may  be  thought  too  tedious 
for  cases  where  the  shape  and  position  of  the  teeth  are  such  that  a  wax 
impression  will  accurately  copy  them ;  but  in  the  great  majority  of 
cases  it  will  be  found  essential  to  accurate  adjustment  to  resort  to  one 
or  other  of  them. 

If  the  clasp  stands  off  from  the  tooth  on  its  coronal  edge,  the  food 
is  apt  to  pack  into  the  wedge-shaped  space  and  loosen  it,  or  even 
change  its  shape ;  if  on  the  edge  near  the  gum,  it  gives  lodgment  to 
the  food  and  mucous  secretions,  to  the  injury  of  the  tooth.  Dr. 
Spalding  recommends,  as  a  preventive  against  such  lodgment,  to  use 
in  all  cases  thick,  narrow  clasps;  to 
attach  them  by  two  or  more  standards  ^^^-  ^^^• 

(Fig.  601),  if  the  clasp  is  long;  to  put 
them  well  up  on  long  teeth,  and  on 
short  teeth,  to  cut  away  the  plate. 
In  this  way  most  of  the  neck  is  ex- 
posed to  the  cleansing  action  of  the 
tongue. 

The  close  adaptation  of  the  clasp  to 
the  surface  of  the  tooth  is  too  often  neglected.  It  is  commonly  done 
with  round  pliers,  making  trial  from  time  to  time  upon  the  tooth  of 
the  model.  This  is  an  uncertain  method  in  any  case,  and  in  many 
utterly  worthless.  Prof.  Austen  advises  always  to  take  a  separate 
plaster  impx'ession  of  the  teeth  to  be  clasped ;  for  which  purpose  a 
small  cup  of  wax,  lead,  or  tin  foil  is  used,  one-eighth  inch  larger  than 
the  tooth.  Let  the  plaster  get  quite  hard  ;  then  slightly  open  the 
impression  ;  withdraw  it,  and  close  up  the  fissure.  Make  from  this 
either  a  plaster  or  a  fusible-metal  tooth  ;  if  the  former,  harden  it  with 
soluble  glass.  With  round  pliers  and  a  hammer,  clasps  can  be  fitted 
with  great  exactness  to  such  a  metallic  tooth.  Extreme  accuracy  of 
fit  may  most  easily  be  obtained  when  the  contour  of  the  tooth  is 
irregular,  by  the  following  method  :  burnish  down  to  the  tooth  a  strip 
of  very  thin  platina ;  then  on  the  outside  of  this  strip  lay  pieces  of 


788  MECHANICS. 

gold  (of  the  fineness  suitable  for  clasps),  with  borax,  and  flow  them 
with  the  blowpipe. 

A  common  error  in  soldering  clasps  is  to  make  their  union  to  the 
plates  too  wide.  Clasps  are  often  called  springs,  but  if  soldered 
through  nearly  their  whole  length,  they  become  rigid  stays,  devoid  of 
elasticity.  There  should  always  be  a  proportion  between  the  size  of 
the  clasp  and  the  width  of  its  attachment;  in  no  case  should  it  exceed 
three-sixteenths  of  an  inch,  and  one-eighth  of  an  inch  is  ample  for  most 
cases.  When  practicable,  the  two  arms  of  a  clasp  should  be  of  equal 
length ;  but  in  short  clasps  it  is  sometimes  preferable  to  throw  all  the 
elasticity  into  a  single  arm.  A  single  attachment  is  better  than  two, 
as  it  gives  more  play  to  the  arms  of  the  clasp  in  the  slight  unavoid- 
able motions  of  the  plate.  Again,  in  shaping  the  plate,  cut  it  well  off 
from  the  tooth,  allowing  a  tapering  tongue  to  extend  up  to  the  clasp, 
for  its  attachment.  In  clasp  pieces  and  in  all  partial  pieces,  remember 
that  the  plate  should  come  in  contact  with  teeth  it  approaches,  or  else 
stand  as  far  off  as  the  case  will  permit ;  the  narrow  band  of  gum  so 
often  left  between  plate  and  teeth  is  liable  to  irritation  by  compression 
between  the  two ;  this  is  productive  of  more  annoyance  and  injury  than 
the  direct  contact  of  the  plate  against  the  tooth. 

Partial  Clasps  or  Stays. — These  differ  from  clasps  in  the  absence 
of  elastic  arms  grasping  the  tooth.  Taking  a  short,  rounded  prism 
(triangular  in  case  of  bicuspids,  in  molars  quadrangular)  as  the 
"type"  of  a  clasped  tooth,  the  clasp  proper  must  grasp  a  side  and 
two  angles  or  two  sides  and  three  angles.  If  it  lies  against  two 
sides  and  one  angle,  or  if  two  opposite  sides  are  so  inclined  (in  the 
line  of  the  clasp)  that  it  will  not  take  hold,  then  it  becomes  merely 
a  stay. 

Stays  demand  for  serviceable  action  a  j^oint  d'appui;  hence  they 
must  be  in  pairs — lying  either  against  the  two  teeth  bounding  an  in- 
terdental space,  or  against  teeth  on  opposite 
Fig.  602.  sides  of  the  mouth.     They  have  great  value 

in  all  partial  cases  where  there  are  no  iso- 
lated teeth  suitable  for  clasps.  Their  func- 
tion is  to  give  stability  to  the  plate  by 
preventing  lateral  motion.  When  the  bicus- 
pids or  molars  have  inclined  or  bulging 
inner  surfaces,  the  stays  hold  the  piece  after 
the  manner  of  a  clasp ;  the  elastic  force  being  given  by  the  plate.  This 
result  can  only  be  obtained,  however,  by  a  very  carefully  taken  plaster 
impression  when  a  vulcanite  plate  is  made,  or,  in  case  of  gold  plate,  by 
getting  the  exact  relation  of  the  parts  by  Dr.  Noble's  method.  It  is  a 
mistake  to  attempt  forcible  retention  of  a  plate  by  the  lateral  thrust  of 


RETENTION   OF   BASE   PLATES. 


789 


stays ;  any  such  pressure  causes  the  teeth  to  yield,  and  then  the  stays 
can  only  act  as  in  the  cases  first  given. 

It  will  be  observed  that  when  the  stay  on  each  side  is  double,  as  in 
Fig.  603,  it  not  only  prevents  lateral  motion,  but  the  points  between  the 
teeth  prevent  backward  motion. 
The  stability  given  in  this  man- 
ner by  stays,  taken  with  an  exact 
adaptation  of  the  plate,  is  far 
more  trustworthy  than  that  given 
by  any  form  of  vacuum  cavity. 

In  connection  with  clasps  we 
shall  briefly  notice  two  methods 
occasionally   practiced    for    the 

retention  of  plates.  First,  by  the  pressure  of  wood  against  the  tooth. 
This  method  was  formerly  much  used  when  human  or  ivory  teeth  were 
set  on  bone.  Stays  were  carved  in  bone  (see  Fig.  603) ;  or  metallic 
stays  or  clasps  were  riveted,  or  grooves  and  cavities  were  cut,  holding 
slips  of  some  hard  wood  which  pressed  against  the  teeth.  This  method 
was  applied  by  Dr.  Stokes  to  metallic  plates — soldering  gold  tubes  to 
the  plate  near  the  teeth,  so  that  the  end  of  the  inserted  wooden  pivot, 
slightly  projecting,  pressed  on  each  side  of  the  tooth  selected. 

Secondly,  by  drilling  into  one  or  two  sound  roots  of  incisors,  canines 
or  bicuspids,  a  short  canal,  and  lining  it  with  a  gold  tube.  Correspond- 
ing pins  soldered  to  the  plate  keep  it  in  place,  much  as  stays  do ;  if  the 
roots  permit  deep  canals,  they  may  retain  it  with  considerable  force. 
Such  a  pin  may  be  used  in  combination  with  a  clasp  or  stay.  Directions 
given  in  chapter  on  pivot  teeth  easily  explain  how  to  prepare  and  attach 
such  pins.  In  some  cases  it  may  be  desirable  to  use  such  a  pin  in  place 
of  clasp  or  stay,  but  the  plate  must  cover  enough  mucous  surface  to 
give  stability.  We  question  the  propriety  of  subjecting  the  roots  of 
two  incisors  to  the  strain  of  five  or  six  teeth  on  a  plate  of  this  kind. 

Where  the  teeth  have  been  recently  extracted,  and  it  is  designed  to 
construct  an  artificial  denture  before  much  change  has  occurred  from 
absorption,  the  front  portion  of  the  plate  should  terminate  within  the 
outer  border  of  the  alveolar  ridge,  and  the  edge  be  scalloped  to  corre- 
spond with  the  festooned  surface  of  the  gum  over  the  cavities  from 
which  the  natural  teeth  have  been  removed. 

Size  and  Outline  Form  of  Special  Cases. — It  is  impossible  to  enumerate 
all  varieties  of  clasp  pieces,  nor  could  we  delineate  under  each  variety 
any  one  form  as  absolutely  best  for  all  its  sub-varieties.  The  more 
philosophical  course  is  to  find,  if  possible,  what  principles,  mechanical 
and  physiological,  determine  the  best  form  in  any  case,  and  to  illustrate, 
by  a  few  examples,  the  application  of  these  principles. 


790  MECHANICS. 

Upper  Incisors. — The  plate  must  not  cover  the  front  of  the  alveolup, 
so  that,  on  front  or  side  views  of  the  mouth,  its  presence  can  be  detected. 
This  rule  applies  also  to  canines  and  front  edges  of  bicuspids.  The 
model  at  these  i^oints  should  be  scraped,  so  that  the  corresponding  die 
shall  give  a  shape  which  will  sink  into  the  gum.  The  plate  must  also 
be  filed  to  a  thin  edge  before  grinding  the  tooth.  With  these  pre- 
cautions a  tooth  or  block  may  have  the  support  of  the  plate  under  the 
centre  of  its  base.  Otherwise,  it  becomes  necessary  to  cut  the  plate 
along  the  line  of  the  backings ;  and  this  is,  in  some  cases,  the  best  plan. 
Incisor  teeth,  if  firmly  bedded  in  the  gum,  may  trust  for  stability  to 
their  hold  in  the  standards,  provided  they  have  been  properly  fitted 
and  soldered. 

The  size  and  shape  of  plate  between  teeth  and  clasps  will  depend 
upon  the  number  of  incisors,  position  of  clasps,  presence  or  absence  of 
other  teeth,  and  upon  peculiarities  of  the  mouth  or  of  the  patient.    For 

Fig.  C04.  Fig.  605. 


the  application  of  the  principles  already  given  to  these  several  condi- 
tions, we  shall  select  a  few  particular  cases. 

One  Incisor. — A  central  or  lateral  may  be  clasped  to  a  first  molar 
on  the  same  side  by  a  plate  clasped  as  in  Fig.  604,  fitting  closely  against 
the  intervening  teeth,  or  by  a  plate,  as  in  Fig.  605.  When  three  or 
more  natural  teeth  intervene  between  the  clasp  and  artificial  teeth,  the 
latter  form  is  preferable,  because  there  is  no  possibility  of  irritating 
the  teeth  by  the  plate  or  by  mucous  deposits.  It  will  be  noticed  that 
the  curve  of  the  plate  is  opposite  that  of  the  dental  arch,  thus  giving 
proximity  to  the  teeth  only  where  it  is  unavoidable.  A  lateral  incisor, 
cuspid  or  bicuspid  may  be  applied  in  the  same  way ;  and  if  the  second 
bicuspid  or  first  molar  is  unfit,  from  its  shape  or  from  decay,  to  be 
clasped,  the  plate  may  be  extended  to  the  second  molar,  or  it  may  be  even 
carried  across  the  mouth,  and  clasped  to  a  plate  on  the  opposite  side  ; 
but  these  modifications  are  suggested  only  in  cases  of  necessity.  Such 
plates  may  be  made  very  narrow,  if  strength  is  given  by  increased 


EETENTION   OF   BASE   PLATES. 


791 


thickness ;  but  too  narrow  plates  are  open  to  the  objection  of  allowing  the 
attached  tooth  to  bed  itself  too  deeply  under  the  pressure  of  masti- 
cation. When  the  form  in  Fig.  604  is  adopted,  it. is  usual  to  direct 
soldering  a  wire  or  band  along  the  festooned  edge,  to  give  strength. 
A  much  better  plan  is  to  gain  strength  by  thickness  of  plate,  and  to 
chamfer  the  plate  along  this  edge.  The  thin  edge  protects  the  gum 
equally  well,  does  not  wear  the  teeth  more  than  the  thick  one,  and  has 
the  decided  advantage  of  giving  no  space  for  lodgment  of  food. 

This  plate  will  permit  attachment  of  clasp  to  the  molar  or  to  either 
of  the  bicuspids,  accordingly  as  one  or  other  of  these  may  be  best  for 
clasping.  Decision  in  this  case  is  based  on  principles  which  apply  to 
many  other  cases.  Supposing  the  three  teeth  well  shaped  and  sound, 
the  molar  is  firmly  implanted  by  its  trifid  root,  and  permits  complete 
encircling  with  the  clasp ;  but  it  is  further  from  the  incisor ;  hence 
there  is  more  strain  upon  tooth  and  clasp.  With  the  clasp  to  the 
second  bicuspid,  the  plate  having  the  same  length  as  before,  we  have 


Fig.  607. 


the  best  possible  application  of  its  retentive  power ;  it  cannot,  however, 
pass  around  the  outside  or  front  angle  of  either  bicuspid,  consequently 
the  clasp  does  not  have  so  firm  a  hold  on  the  tooth.  The  same 
remarks  apply  with  even  more  force  to  the  first  bicuspid.  There  will 
usually  be  some  modifying  circumstances  to  determine,  in  this  class  of 
cases,  choice  of  the  clasp  tooth. 

Two  or  Four  Incisors. — Two  incisors  may  be  attached  to  a  plate 
shaped  as  for  one  (Fig.  604),  with  the  addition  of  a  second  clasp,  when 
the  teeth  permit.  But  much  the  best  practice  is  to  select  the  second 
tooth  on  the  opposite  side.  Fig.  606  gives  the  form  when  it  is  decided 
to  run  the  plate  up  to  the  intervening  teeth.  Fig.  607  represents  the 
second  form,  better  suited  than  the  first  in  certain  cases  of  two  incisors. 
With  four  incisors  and  clasps  on  second  bicuspids,  the  first  form  is 
best,  because  only  two  teeth  lie  between  the  incisors  and  clasp ;  and  it 
is  better  to  carry  the  plate  up  to  the  teeth  than  to  expose  so  small  a 


792 


MECHANICS. 


Fig.  608. 


portion  of  gum.     For  four  teeth,  the  plate  should  be  rather  wider  than 
for  two. 

lu  these  cases  a  closely-fitting  plate  assists  so  much  in  its  own 
retention,  that  bicuspid  stays  will  often  suffice  to  retain  them,  or  a  clasp 
on  one  side  and  a  stay  on  the  other.  When  the  adhesion  of  the  plate 
to  the  gum  is  thus  partly  relied  upon,  it  is  not  necessai-y  to  make  the 
olate  for  four  incisors  larger  than  in  Fig.  606. 

When  the  patient  is  very  intolerant  of  the  presence  of  much  metal 
in  the  mouth,  two  teeth  may  sometimes  be  securely  inserted,  as  sug- 
gested by  Dr.  Maynard,  upon  a  T-shaped  plate — the  cross-piece,  one- 
fourth  to  three-eighths  of  an  inch  wide,  fitting  the  arch  from  bicuspid 
to  bicuspid  ;  the  slip  to  which  the  tooth  is  attached  being  soldered 
to  the  centre,  and  also  fitting  the  arch.  Such  a  piece,  well  made,  will 
resist  considerable  traction  upon  the  incisor.  Owing  to  the  peculiarity 
of  its  shape,  the  attempt  to  draw  down  the  tooth  springs  the  transverse 
slip  of  metal,  and  causes  it  to  bind  upon  the  bicuspids. 

When   the  four  incisors  and  the  cuspids  are  to   be  replaced,  the 

construction  of  the  plate  (Fig.  606) 
is  upon  precisely  the  same  principle 
as  the  preceding,  the  only  differ- 
ence being  that  the  plate  should  be 
rather  larger.  AVhen  the  teeth  on 
one  side  of  the  mouth  are  too  much 
decayed,  or  are  incapable  of  afford- 
ing a  secure  attachment,  or  are 
missing,  even  this  number  of  teeth 
may  be  held  by  one  clasp  on  one 
side  of  the  mouth  and  a  stay  on  the 
other.  But  the  plate  should  be  extended  half  or  three-fourths  of  an 
inch  back  of  the  tooth  to  which  it  is  clasped.  If  this  precaution  is 
neglected,  the  piece,  from  its  weight,  may  act  as  a  lever  upon  the  tooth, 
and  loosen  it  or  cause  periostitis.  It  sometimes  happens  that  a  piece 
made  originally  with  clasps  on  both  sides  of  the  mouth  loses  the 
benefit  of  one  clasp  from  the  loss  of  the  tooth ;  and  yet  the  patient 
retains  it  in  place  as  well  as  before.  The  piece  is  then,  in  part,  retained 
by  the  fit  of  the  plate  to  the  gum  ;  from  which  we  learn  that  if  only 
one  clasp  can  be  attached  to  a  plate  with  from  four  to  six  teeth,  it  is 
advisable  to  cover  rather  more  of  the  surface  of  the  mouth.  In  this 
combination  the  clasp  and  stay  give  steadiness,  and  the  close  fit  of  the 
plate  to  the  gum  gives  adhesion. 

Upper  Bicuspids. — One  or  both  bicuspids  on  one  side  are  often 
attached  to  a  plate  about  the  size  of  a  cent,  clasped  to  the  bicuspid  or 
molar  behind.   But  such  pieces  are  not  of  much  service  in  mastication. 


RETENTION  OF  BASE  PLATES. 


793 


It  is  better  practice  to  leave  such  a  space  unfilled,  than  endanger  the 
durability  of  a  good  tooth  by  clasping  it.  If  there  is  a  bicuspid  space 
on  either  side,  the  plate  crosses  the  mouth.  Fig.  609  represents  such 
a  plate  clasped  to  the  first  molar  and  fitted,  as  is  very  commonly  done, 
closely  to  the  incisors.  But  in  this  and  all  other  cases  where  the  four 
or  six  front  teeth  remain,  it  is  decidedly  better  to  leave  as  large  a 
space  between  the  plate  and  the  teeth  as  possible.  The  sti*ength  of  the 
plate  is  preserved  by  giving  less  curve  to  the  back  edge,  or  by 
doubling  the  plate  in  the  middle.  The  design  of  this  form  is  not 
merely  to  keep  the  plate  from  the  front  teeth,  but  to  leave  uncovered 
the  part  of  the  mouth  immediately  behind  the  incisors.  Two  important 
points  are  gained  by  this.  The  sense  of  taste  is  more  impaired 
by  covering  this  part  of  the  palatine  surface  than  any  other — not 
because  fibres  of  the  gustatory  nerve  have  any  special  distribution 
here,  but  because  of  the  univei'sal  habit  of  pressing  the  tip  of  the 

Fig.  609.  Fig.  610. 


tongue  here,  in  the  act  of  tasting  ;  and  pressure  against  the  natural 
mucous  surface  develops  this  sense  most  fully.  Secondly,  the  articu- 
lation of  the  dental  letters  (the  mutes  T,  D,  Th,  the  nasal  N  and  the 
liquid  L)  is  thickened  by  a  plate  covering  this  part.  Such  covering  is 
in  many  plates  necessary ;  but  it  is  well  to  avoid  it,  for  the  above 
assigned  reasons,  whenever  possible. 

When  the  loss  of  bicuspids  is  accompanied  by  that  of  the  six  front 
teeth,  and  the  first  molars  alone  remain,  a  good  form  of  plate  is  shown 
in  Fig.  610.  The  backward  extension  of  the  plate,  curving  partly 
over  the  alveolus,  is  designed  to  prevent  the  weight  of  the  piece  from 
acting  injuriously  on  the  molars,  and  to  assist  their  retentive  power. 
If  the  second  molars  are  also  in  the  mouth,  the  extended  plate  must  be 
diflferently  shaped.*     If  the  molars  are  well  shaped  and  firm,  the  plate 

*  The  festooned  shape  of  this  and  similar  cuts  is  designed  to  mark  the  number 
and  position  of  the  artificial  teeth.  The  forms  of  the  teeth  are  om'tted,  as  having 
nothing  to  do  with  the  subject  of  this  chapter.  The  plates  on  the  models  are 
taken  from  the  valuable  work  of  Prof.  Richardson. 


794  MECHANICS. 

may  be  narrower  than  here  represented,  being  careful  to  make  it 
thicker  also.  But  if  the  presence  of  adjacent  molars  prevents  the  use 
of  complete  clasps,  or  if  their  form  renders  stays  necessary  instead  of 
clasps,  the  plate  may  be  rather  wider.  Be  careful,  however,  not  to 
cover  the  hard  floor  of  the  palate,  or  to  attempt  giving,  by  a  cross 
band  at  the  back  of  the  plate,  the  stiffness  which  is  best  gained  by 
thickness  of  metal. 

Plates  of  this  class  are  kept  in  place  as  much  by  the  adhesion  of  con- 
tact with  the  gum  as  by  the  clasps.  In  many  cases  the  force  of  adhe- 
sion is  such,  that  the  lateral  support  of  stays  is  quite  as  effectual  as 
clasps.  Hence,  after  a  clasp  piece  of  this  kind  has  been  worn  for  some 
time  and  become  perfectly  set  to  the  mouth,  it  may  be  advisable  to 
shorten  the  clasps  into  stays  ;  indeed,  it  is  better  practice,  in  all  cases, 
to  anticipate  this  ultimate  fit  of  these  plates,  and  make  stays  at  first 
instead  of  clasps.  This  applies  with  still  more  force  to  the  loss  of 
twelve  teeth,  the  second  molars  remaining,  which  should  in  no  case  be 
clasped  ;  stays  may  very  properly  be  used  to  prevent  lateral  or  back- 
ward motion  of  the  plate.  The  presence  of  these  second  molars,  by 
giving  lateral  steadiness  to  the  plate,  prevents  all  necessity  for  covering 
the  hard  palate,  and  makes  a  vacuum  cavity  wholly  uncalled  for.  A 
solitary  molar  should  never  be  clasped,  nor  should  it  be  allowed  to 
remain  in  the  mouth. 

Alternate  Spaces. — It  remains  to  consider  the  forms  of  plates  for 
vacancies  alternating  with  natural  teeth.  The  forms  given  for  four 
incisors  will  answer  for  all  alternating  vacancies  anterior  to  the  second 
bicuspids,  remembering  to  make  the  plate  wider  in  proportion  to  the 
number  of  teeth,  and  thicker  in  proportion  as  it  is  made  narrow  ;  also, 
that  a  first  bicuspid  may,  in  many  of  these  cases,  be  clasped  with  better 
effect  than  a  second,  or  than  the  first  molar.  Fig.  611  is  a  good  type  for 
cases  where  the  vacancies  include  the  bicuspids ;  notice  in  this  cut 
the  backward  extension  of  the  plate.  Where  the  natural  teeth  are  in 
groups  of  two,  it  is  best  to  carry  the  plate  close  up ;  if  as  many  as 
three  or  four  are  together,  the  plate  may  be  cut  away,  especially  if 
they  are  incisors.  Fig.  612  represents  an  exceptional  case,  in  which 
two  laterals  and  two  left  bicuspids  are  attached,  by  clasping,  to  the 
right  first  bicuspid  and  molar.  The  left  molars  are  supposed  to  be 
loose,  or  sockets  much  absorbed,  or  from  some  other  cause  forbidding 
clasps  or  stays.  In  this  case,  the  undue  strain  on  the  clasp  teeth  will 
ultimately  cause  their  loss.  Whenever  an  unavoidable  strain  of  this 
kind  is  thrown  upon  a  tooth,  a  clasp  may  be  used  in  preference  to  cov- 
ering the  palate,  provided  the  patient  is  content,  for  the  sake  of  the 
firmness  which  it  gives,  to  risk  the  loss  of  the  tooth.  Teeth  are  more 
firmly  retained  by  clasps  than  by  atmospheric  pressure,  and  this,  with 


EETENTION    OF   BASE   PLATES. 


795 


many  patients,  outweighs  all  considerations  of  injury  to  the  other 
teeth. 

Partial  pieces,  with  alternating  spaces,  do  not  acquire  that  adhesion 
by  contact  found  in  cases  where  the  lost  teeth  lie  together.  The  inter- 
rupted margin  between  the  teeth  so  readily  admits  air  under  the  plate, 
on  the  slightest  motion,  that  the  atmospheric  pressure  is  imperfectly 
applied.  Hence  there  is  continued  demand  for  the  retentive  power  of 
the  clasps.  The  vacuum  cavity  does  not  correct  this  difficulty,  or 
supply  the  place  of  clasps,  since,  as  will  be  explained  in  the  next 
section,  the  vacuum  acts  on  soft  membrane  and  has  necessarily  a  tem- 
porary force. 

When  the  six  or  eight  front  teeth  remain,  a  plate  holding  bicuspids 
and  molars  cannot  be  retained  by  clasps.  In  the  first  place  the  cuspids 
could  not  be  clasped,  nor  would  it  be  proper  even  to  carry  stays  against 
them.     In  the  latter  case,  the  weight  and  leverage  of  the  piece  would 


Fig.  611. 


Fig.  612. 


be  too  great  for  the  slight  clasp  that  a  first  bicuspid  permits  ;  but  two 
stays,  with  the  points  passing  as  far  to  the  front  of  the  bicuspids  as  the 
cuspids  allow,  would  tend  to  prevent  the  slipping  of  the  plate  back- 
ward. 

Lower  Partial  Pieces. — These  do  not  properly  come  under  the  head 
of  clasp  work.  In  replacing  one  or  more  incisors,  lost  by  accident  or 
salivary  calculus,  half-clasps  may  be  applied  to  the  bicuspids.  For 
such  cases  the  best  style  of  work,  beyond  all  question,  is  a  vulcanite 
plate,  made  on  a  model  from  a  plaster  impression.  Fitting  with  great 
accuracy  the  inner  surfaces  of  the  bicuspids,  it  is  firmly  held  without 
injury  to  the  retaining  teeth.  Partial  pieces  filling  bicuspid  and  molar 
vacancies  should  not  clasp  cuspids  or  bicuspids ;  the  position  of  re- 
maining molars  seldom  permits  clasping ;  even  stays  cannot  always  be 
applied. 

In  chapter  fourth,  on  Preparatory  Treatment  of  the  Mouth,  the  ques- 
tion of  extracting  molar  or  bicuspid  teeth,  which  might  otherwise  be 


796  MECHANIC^. 

used  for  clasping,  is  considered.  The  importance  of  permanence  of 
the  work  outweighs  any  temporary  advantage  resulting  from  clasping 
one  or  two  such  teeth.  In  chapter  third,  and  in  the  section  on  Reten- 
tion by  Clasps,  are  many  remarks  which  it  is  unnecessary  to  repeat, 
but  which  are  important  for  the  full  understanding  of  the  details  of 
construction  given  in  this  section. 

PLATES    RETAINED    BY   ATMOSPHERIC   PRESSURE. 

Of  the  two  methods  of  retaining  a  dental  appliance  already  con- 
sidered, the  first,  by  springs,  is  suited  only  to  entire  dentures ;  the 
second,  by  clasps,  is  adapted  only  to  partial  cases.  The  principle  of 
retention  now  to  be  considered  is  applicable  to  both ;  where  practicable, 
it  is  the  most  perfect  way  of  retaining  a  set  of  artificial  teeth.  If  the 
pressure  of  the  atmosphere  could  be  removed  from  the  mucous  side  of 
.a  plate,  allowing  its  full  force  to  be  exerted  upon  the  lingual  surface, 
the  smallest  plates  would  adhere  with  a  force  of  four  pounds,  the 
largest,  forty.  But,  for  reasons  to  be  given,  plates  seldom  have  one- 
fourth  of  this  resistance  to  displacement.  There  are  two  methods  in 
present  use  for  securing  the  service  of  atmospheric  pressure.  One  is 
by  close  adaptation  of  the  plate;  the  other,  by  construction  of  a  cavity 
of  definite  form.  Both  act  by  the  more  or  less  perfect  exclusion  of 
air  from  between  the  plate  and  the  mouth.  The  first  Avill  be  con- 
sidered as  the  Adhesion  of  Contact;  the  second  as  the  power  of  the 
Vacuum  Cavity.  Before  describing  the  separate  application  of  these 
to  dental  plates,  a  few  remarks  are  necessary,  in  addition  to  what  has 
already  been  said  in  the  last  section  of  the  third  chapter,  in  exposition 
of  the  general  principles  of  atmospheric  pressure. 

The  surfaces  of  two  pieces  of  highly  polished  ground  glass,  if  pressed 
together,  will  adhere  firmly  ;  so  much  so,  sometimes,  as  to  resist  every 
attempt  at  separation.  Surfaces  less  smooth  and  close-grained  will 
also  adhere  with  great  tenacity,  if  their  pores  or  irregularities  are 
filled  by  wetting  with  water.  If  both  surfaces  are  rigid,  they  may  be 
made  to  slide  upon  each  other,  but  will  resist  a  force  of  five  to  fifteen 
pounds  for  every  square  inch,  if  applied  at  right  angles  to  the  surface; 
if  one  surface  is  soft  and  pliant,  it  becomes  difficult  to  keep  it  in  con- 
tact around  the  edges.  Traction  upon  the  centre,  as  in  the  case  of  a 
disc  of  wet  leather  upon  a  flat  stone,  will  draw  in  the  edges,  and  create 
a  vacuum  in  the  centre.  It  might  be  supposed  that  in  this  vacuum 
space  lies  the  power  that  raises  the  stone ;  whereas,  it  lessens  the 
power  by  reducing  the  area  of  stone  in  contact  with  the  leather,  even 
if  the  vacuum  is  perfect.  Still,  if  the  entire  circumference  is  in  con- 
tact, no  air  enters  the  cavity,  except  what  passes  through  the  porous 
leather,  and  for  a  time  the  lifting  power  of  the  disc  is  sufficient  to 


RETENTION  OF  BASE  PLATES.  797 

raise  the  stone.  If  traction  be  made  upon  the  disc  anywhere  but  in 
the  centre ;  the  flexible  edge  will  be  raised ;  air  enters  between  the 
surfaces,  and  counteracts  that  pressure  on  the  under  side  of  the  stone 
which  was  the  lifting  force. 

Hence,  between  two  surfaces  adhering  by  simple  contact,  one  of 
which  is  soft  and  pliant,  adhesion  is  not  so  persistent  as  where  both 
are  rigid,  because  of  the  liability  to  separation  around  the  edges 
admitting  air  between  the  surfaces.  Applying  this  to  dental  plates, 
we  may  understand  their  liability  to  become  detached  by  a  degree  of 
motion  which  separates  them  from  the  gum  at  any  one  point  around 
the  edge.  We  learn,  also,  that  so  long  as  absolute  contact  is  main- 
tained, we  have  the  most  perfect  exclusion  of  air  practicable  ;  hence, 
no  force  of  adhesion  in  a  limited  vacuum  cavity  (the  perfect  exhaustion 
of  which  is  impossible)  is  comparable  to  the  adhesion  of  the  entire 
surface  of  the  plate,  provided  this  is  made  as  perfect  as  possible  by 
accurate  workmanship,  and  is  not  weakened  by  the  admission  of  air 
around  the  edges. 

If  we  exhaust  the  air  from  the  barrel  of  a  key,  and  apply  the  lip,  it 
will  be  drawn  in,  and  held  with  a  force  sufiicient  to  suj^port  the  weight 
of  the  key  for  some  time.  This  simple  experiment  will  prove,  on 
examination,  very  instructive.  The  mucous  and  submucous  tissues  are 
pressed  into  the  key,  because  the  fluids  j)ervading  these  parts,  being 
under  pressure  in  every  other  direction,  tend  toward  the  point  from 
which  the  pressure  is  wholly  or  partially  removed.  The  extent  to 
which  the  lip  is  drawn  into  the  key  will  depend  upon  two  conditions. 
First,  the  softness  and  mobility  of  the  tissue ;  secondly,  the  shape  of 
the  edge  of  the  orifice.  If,  in  addition  to  these  two  points,  we  inquire, 
thirdly,  why  the  key,  after  a  time,  drops  ofi*,  we  shall,  from  this  simple 
illustration,  have  fully  explained  the  rationale  of  the  vacuum  cavity, 
as  applied  for  the  retention  of  a  piece  of  dental  mechanism. 

First :  the  extent  to  which  or  rapidity  with  which  a  partial  vacuum 
becomes  filled  up  by  any  yielding  tissue  with  which  it  is  brought  in 
contact,  depends  upon  the  mobility  of  its  structure.  We  say,  partial 
vacuum,  because  the  process  of  mechanical  exhaustion  can  never  pro- 
duce a  perfect  vacuum.  If  the  water  which  gives  softness  to  mucous 
tissues  was  perfectly  free  to  move,  the  cavity  w^ould  be  instantly  filled, 
however  deep.  Parts  as  mobile  as  the  tongue  and  lips  yield  readily 
to  this  fluid  pressure;  but  the  mucous  membrane  of  the  alveolar  ridge 
and  palate,  being  more  or  less  tied  down  to  the  bone,  fills  the  cavity 
more  slowly;  if  too  deep,  it  will  not  fill  it  at  all,  except  by  hypertrophy. 
Reverting  to  the  experiment  of  the  key :  if  violent  suction  is  made,  a 
purple  spot  is  left  upon  the  lip;  the  mucous  tissues  being  prevented 
by  their  structure  from  filling  the  vacuum,  the  fluids  still  feel  the 


798 


MECHANICS. 


impulse  of  atmospheric  pressure;  the  blood,  thus  impelled  with  a 
force  which  the  thin  capillary  walls  cannot  resist,  is  extravasated,  as 
takes  place  also  in  the  application  of  "dry  cups."  Hence,  where  a 
dental-plate  cavity  is  so  deep  that  the  tissues  cannot  fill  it,  if  the 
degree  of  exhaustion  is  such  as  still  to  draw  upon  the  surface,  the 
tissues  are  in  danger  of  being  ruptured.  Such  a  source  of  irritation 
will,  in  many  persons,  develop  morbid  action,  and  should  forbid  the 
use  of  deep  cavities  in  any  plate. 

Secondly:  the  shape  of  the  edge  modifies  the  rapidity  with  which 
the  cavity  fills.  If  the  edge  of  a  cupping  glass  is  rounded,  the  skin 
glides  under  it,  and  is  drawn  from  the  adjoining  parts  into  the  glass ; 
but  if  the  glass  is  ground  so  as  to  present  a  sharp  edge  on  the  inside, 
this  beds  itself  in  the  surface,  and  prevents  so  much  of  the  adjacent 
skin  from  being  drawn  in.  It  rises  to  a  less  height  in  the  cup,  and  the 
remaining  force  of  the  vacuum  is  spent  upon  the  capillary  vessels, 
which  are  ruptured.  Hence,  we  learn  that  sharp-edged  cavities  fill 
less  rapidly,  but  act  with  more  power  upon  the  tissues ;  they  are  con- 
sequently more  apt  to  excite  disease,  if  the  cavity  has  sufiicient  depth 
to  allow  continued  action. 

Thirdly :  as  to  the  cause  of  the  final  dropping  oif  of  the  key :  water, 
and  all  the  moist  tissues  of  the  body,  contain  atmospheric  air,  which 
they  yield  up  under  a  vacuum.  Hence,  a  mucous  membrane,  although 
at  first  drawn  strongly  into  a  cavity,  will  make  the  vacuum  less  com- 
plete, by  giving  out  the  air  contained  in  its  tissue  and  in  the  blood 
constantly  circulating  through  it.  The  adhesion  of  a  vacuum,  there- 
fore, over  mucous  membranes,  requires  renewal  by  occasional  suction; 
since  the  blood  is  constantly  circulating  through  the  surface,  and  sup- 
plies air  to  the  cavity.  Mucous  membranes  have  also  the  property  of 
absorbing  air;  as  is  seen  in  the  lining  of  the  bronchial  cells  constantly, 
and  in  the  power  of  the  mucous  membrane  of  the  intestines  to  absorb 
the  gases  there  generated.  This  property  acts  an  important  part  in 
absorbing  small  quantities  of  air  unavoidably  caught  between  the 
plate  and  the  mouth ;  thus  partly  explaining  the  well-known  fact,  that 
plates  adhering  by  simple  contact  become  tighter  after  being  worn 
awhile. 

Thus  the  double  action  of  mucous  membrane,  absorbing  minute  por- 
tions of  air  pressed  against  it,  and  giving  out  its  contained  air  to  a 
vacuum,  favors  the  retention  of  simple  contact,  whilst  it  acts  against 
the  efficacy  of  the  vacuum.  In  either  case  it  prevents  the  full  force 
of  pressure,  theoretically  possible.  The  practical  inference  from  the 
lesson  of  the  key  is,  that  the  Vacuum  Cavity  acts  well  at  first,  and 
may  be  useful  for  the  temporary  purpose  of  retaining  a  plate,  until 
the  changes  of  which  the  mouth  is  capable  adapt  it  more  perfectly  to 


RETENTION    OF    BASE    PLATES. 


799 


the  plate ;  but  for  permanent  adhesion,  the  only  reliable  application 
of  the  atmospheric  pressure  principle  is  the  Adhesion  of  Contact,  which 
is  fully  developed  only  when  the  contact  of  the  plate  is  complete.  A 
vacuum  cavity,  acting  as  such,  gradually  draws  the  gum  into  it,  and 
finally  fills  it  by  a  more  or  less  permanent  enlargement;  when  thus 
filled,  the  plate  is  retained  solely  by  the  adhesion  of  contact.  When 
a  cavity,  intended  to  hold  up  a  plate,  leaves  no  prominence  or  mark 
in  the  mouth,  it  unmistakably  proves  that  it  is  exerting  no  force ;  so 
far  from  aiding  in  the  retention  of  the  plate,  it  diminishes  the  force  of 
adhesion  by  the  presence  of  air,  and  has  no  compensating  advantage, 
except  in  removing  pressure  from  a  hard  palate  membrane.  There 
are,  however,  other  and  better  ways  of  obtaining  an  air  space,  as  else- 
where explained,  without  the  presence  of  a  cavity,  which  marks  the 
failure  of  its  original  purpose. 


ADHESIPN  OF  CONTACT. 

Full  plates,  which  are  designed  to  adhere  by  force  of  contact,  differ 
from  those  retained  by  spiral  springs,  in  that  the  former  are  larger  than 
the  latter,  covering  more  of  the  palate,  so  as  to  give  a  larger  surface 
for  the  pressure  of  the  atmosphere.  They  may  cover  the  whole  of  the 
outer  surface  of  the  alveolar  ridge,  and  a  considerable  portion  of  the 
roof  of  the  mouth ;  but  should  not  go  as  far  back,  nor  run  so  high  up, 
as  some  dentists  are  in  the  habit  of  extending  them.  If  allowed  to 
cover  those  parts  of  the  bone  where  the  cheek  muscles  on  the  outside 
of  the  ridge  or  the  palate  muscles  at  the  back  of  the  mouth  are 
inserted,  the.  gums  will  be  chafed  or  ulcerated,  the  patient  nauseated, 
and  the  piece  rendered  unstable  by  the  action  of  the  muscle.  It  is 
not  always  necessary  to  employ  a  very  wide  plate  to  give  secure  reten- 
tion, 'for  a  comparatively  narrow 
one  will  often  adhere  with  very 
great  tenacity  to  the  gums.  Eut 
such  a  plate  is  more*  liable  to  be 
bent,  and  lose  its  perfect  adapt- 
ation to  the  parts,  than  a  wide  one, 
unless  made  thicker  in  proportion 
as  it  is  narrower.  As  it  is  never 
necessary  to  make  an  upper  plate 
so  narrow  as  a  lower  one,  thei'e  can 
be  no  difficulty  in  giving  the 
requisite  strength,  either  by  in- 
creasing the  thickness  throughout, 
or  by  doubling  the  anterior  half. 

The   diagram    (Fig.    613)    represents    half-section   outlines    of  six 


Fig.  618. 


800  MECHANICS. 

modifications  of  form  in  the  posterior  margin  of  the  plate,  where 
it  is  proposed  to  overcome  the  difficulties  incident  to  a  hard 
palatine  membrane  by  cutting  out  the  plate.  The  line  P,  curving 
forward  from  a  little  behind  the  termination  of  the  top  of 
the  ridge  (dotted  line),  is  the  extreme  limit  of  any  plate  not 
complicated  with  cleft  palate.  The  curve  a  or  a'  will  give  surface 
sufficient  for  the  retention  of  most  plates,  except  in  small  arches.  This 
form  is  more  agreeable  to  the  patient  than  the  first,  and  is  less  apt 
to  produce  nausea ;  it  removes  the  plate  from  all  action  of  the  palate 
muscles,  and  lessens  the  liability  to  dislodgment  often  caused  by  the 
forcible  action  of  the  tongue  against  the  back  of  the  palate,  in  certain 
efforts  of  deglutition.  The  curve  h  or  h"  may  often  be  used  solely  to 
avoid  unnecessary  covering  of  the  palate.  In  mouths  of  average  size, 
and  having  moderate  and  regular  softness,  such  shape  will  prove  quite 
as  firm  as  one  following  the  line  P.  But  these  lines  are  more  frequently 
to  be  followed,  for  the  same  reason  that  we  take  the  curve  c  or  c\  to  keep 
the  plate  off  the  hard  central  ridge.  When  this  ridge  is  narrow,  we 
give  greatest  width  to  the  plate  by  following  the  curves  on  the  side  R 
of  the  diagram  ;  but  if  the  surface  is  broad,  the  space  must  be  widened, 
as  on  the  side  L  ;  and  the  plate  made  thicker. 

This  method  of  relieving  the  central  bearing  of  plates  gives  them 
great  steadiness  on  the  ridge,  and  has  an  advantage  over  other 
methods,  in  having  no  band  or  ridge  of  plate  pressing  along  the  line 
P — a  point  very  often  as  hard  as  any  other  part  of  the  palate.  It  is 
advisable,  in  those  cases  where  a  vacuum  cavity  has  been  tried  with 
unsatisfactory  results,  to  cut  out  the  cavity  and  part  behind  it,  and 
thus  try  the  effect  of  a  plate  following  curve  h  or  c. 

There  are  other  methods  of  taking  off  the  central  bearing  of  plates. 
When  the  ridge  is  soft,  a  wax  impression  does  this  by  compressi^fig  the 
gum.  Models  from  plaster  impressions  are  scraped  on  the  ridge  for 
the  same  purpose  ;  but  this  is  not  so  good  a  plan,  as  it  is  difficult  to  do 
it  uniformly.  A  much  better  expedient  is  to  brush  some  thin  plaster 
over  the  central  part  of  the  model,  being  careful  to  mark  the  line  of 
the  back  edge  of  the  plate,  and  put  no  plaster  there;  this  layer  must 
not  be  thicker  than  a  card,  and  should  have  no  abrupt  edges.  In  deep 
arches,  the  shrinkage  of  the  zinc  die  accomplishes  the  same  object ;  if 
the  model  is  carefully  scraped  along  the  back  edge  of  the  plate,  this 
part  will  fit  closely,  while  the  central  portions  will  stand  off;  this  is 
far  better  than  the  attempt  to  adjust  the  edge  with  pliers. 

In  adapting  atmospheric-pressure  plates,  the  form  and  fit  of  the 
alveolar  margin  must  be  considered.  Close  adaptation  of  this  edge  is 
by  no  means  so  essential  to  firm  retention  of  a  full  upper  piece  as  in 
the   posterior  margin  ;  for  the  reason  that,  in  most   cases,  the  loose 


EETENTION  OF  BASE  PLATES.  801 

raucous  folds  which  lie  against  the  plate  prevent  the  access  of  air. 
But  closeness  of  fit  is  very  desirable  for  other  reasons :  to  prevent 
lateral  motion ;  to  avoid  unnecessary  fullness ;  to  prevent  irritation  of 
the  soft  parts  by  projecting  edges  of  metal.  The  form  of  the  alveolar 
edge  is  not  essential  to  adhesion,  provided  it  rises  high  enough  to  give 
steadiness  to  the  plate.  Jisthetic  considerations,  however,  often  compel 
us  to  run  the  plates  up  as  high  as  the  muscular  attachments  will  per- 
mit ;  either  for  the  support  of  an  artificial  gum  or  to  restore  sunken 
features.  In  both  jaws,  especially  the  lower,  the  effort  to  get  the  deep- 
est possible  edge  often  gives  instability,  by  subjecting  the  piece  to  the 
action  of  the  facial  and  lingual  muscles.  In  any  case  of  doubt  make 
the  plate  too  shallow  rather  than  too  deep  ;  especially  when  the  edge 
is  turned  over,  which  makes  it  impossible  to  take  ofi*  any  excess  without 
spoiling  the  plate. 

Full  lower  plates  are  held  by  adhesion  of  contact ;  but  in  these  the 
weight  of  the  piece  increases  the  adhesion.  The  surface  is  so  small 
that  every  part  of  such  plates  should  fit  the  gum  with  accuracy.  The 
simple  rule  for  the  form  of  lower  plates  is  to  extend  them  as  far  on  the 
inner  and  outer  edges  as  the  muscular  attachments  will  permit.  The 
outer  and  inner  edges  are  often  rounded  by  soldering  a  gold  wire, 
after  determining  the  exact  outline.  Thickness  of  edge  is  also  given 
by  doubling  the  plate  necessary  for  the  strength  of  narrow  plates.  The 
second  plate  is  to  be  swaged  precisely  as  the  first ;  then,  after  partial 
trimming,  the  two  plates  are  swaged  together  over  a  new  die.  One 
should  be  wider  than  the  other,  on  the  outer  or  inner  edge,  to  give  a 
place  for  the  .solder ;  the  borax  cream  should  be  free  from  granules, 
and  the  blowpipe  flame  directed  on  the  edge  opposite  the  solder.  A 
simple  and  convenient  clamp  for  binding  plates  together,  or  holding 
rims  while  being  soldered,  is  made  of  iron  (or  nickel)  wire  (Fig.  614). 
a  The  first  bend ;  b  the  second  bend  ;  e  a 
side   view   of  the   same  ;    d  side  view   of  ^^^-  ^^^• 

clamp,  open  and  grasping  two  pieces  of 
plate.  The  curves  should  be  so  adjusted 
that  the  points  of  contact  with  the  plates 
will  be  just  opposite,  else  clamp  or.  plates 
are  liable  to  change  position. 

Partial  pieces  may  also  be  retained  by 
closeness  of  adaptation  ;  but  there  are  two 
elements  of  instability  which  usually  will 
prevent  them  from  having  the  security  of 
full  sets,  or  of  partial  clasp  pieces — lateral  movement  and  extent  of 
margin,  admitting  air  on  slightest  motion.  All  such  pieces  should,  if 
possible,  have  two  stays,  one  on  each  side  of  the  mouth,  to  prevent 
51 


802  MECHANICS. 

lateral  motion  ;  they  should  cover  an  extent  of  surface  proportioned 
to  the  number  of  teeth  ;  the  edges  of  the  plate  should  fit  with  great 
accuracy.  If  the  exact  outline  of  the  plate  is  determined  on,  a  good 
plan  is  to  paint  the  model  with  a  coat  of  thin  plaster,  keeping  one- 
eighth  inch  inside  the  margin,  and  laying  an  extra  coating  over  very 
hard  places;  this  causes  the  edge  to  sink  slightly  into  the  gum  ;  yet 
if  carefully  done,  it  will  not  change  the  general  contour  of  the  surface. 
Partial  plates,  holding  the  eight,  ten  or  twelve  anterior  teeth,  if 
assisted  by  stays  against  the  remaining  molars,  are  nearly  or  quite  as 
firm  as  full  plates.  But  in  either  partial  or  full  pieces,  whenever  the 
plate  has  to  be  cut  off,  for  setting  the  six  front  teeth  directly  on  the 
gum,  this  dentated  margin  is  more  apt  to  admit  air  than  the  upturned 
rim,  which  has  the  folds  of  the  lip  lying  against  it.  Partial  lower 
plates  are  unstable,  not  from  any  admission  of  air,  but  because  of  the 
small  extent  of  surface,  inadequate  to  the  pressure  of  mastication. 

THE   VACUUM   CAVITY. 

In  some  mouths  the  base  plate  of  a  full  upper  piece  adheres,  from 
the  beginning,  with  great  firmness.  When  the  gum  is  moderately  and 
regularly  soft,  the  palatine  arch  deep,  and  the  mouth  of  average  size, 
want  of  adherence,  on  trial  of  the  plate,  is  positive  evidence  of  defect 
in  construction.  But  very  hard,  or  very  small,  or  very  shallow  mouths 
usually  require  time  for  the  perfect  adaptation  of  the  best  made  plates. 
Dr.  Dwindle  thus  explains  the  temporary  failure  of  a  simple  atmos- 
pheric pressure  plate  to  fit  firmly  when  first  inserted.  When  the  plate 
is  applied  and  an  effort  made  to  exhaust  the  air,  the  gums  are  drawn 
down  so  as  to  meet  it  along  the  line  and  behind  the  edge  of  the  plate, 
thus  resisting  every  effort  made  from  without  to  withdraw  the  air 
from  the  central  part  of  the  plate;  so  that  the  pressure  of  the 
atmosphere  is  exerted  upon  only  a  small  breadth  of  surface  along 
its  edge,  where  the  adhesion  is  constantly  liable  to  be  disturbed  in 
mastication. 

With  the  view  of  obviating  this  difficulty,  the  idea  of  constructing 
a  plate  with  a  cavity  suggested  itself  to  the  author  as  early  as  1835, 
and  was  mentioned  at  the  time  to  several  of  his  professional  brethren. 
The  construction  of  the  chamber  then  devised  was  found  objectionable, 
and  he  abandoned  its  use  ;  and  it  was  not  until  the  early  part  of  1848, 
when  he  had  the  opportunity  of  seeing  a  cavity  plate  upon  a  plan 
contrived  by  Dr.  J.  A.  Cleaveland  two  or  three  years  previously,  that 
he  was  again  induced  to  construct  a  base  plate  of  this  kind.  Dr. 
Dwindle  made  a  cavity  plate  with  an  external  opening  and  valve  for 
exhausting  the  air,  in  the  winter  of  1845  ;  and  in  the  summer  of  1847 
or  1848  Dr.  Jahial  Parmly  exhibited  to  the  author  a  plate  with  a 


RETENTION  OF  BASE  PLATES.  803 

simple  cavity  struck  into  it  by  swaging.  Some  months  after  lie  heard 
for  the  first  time  of  a  cavity  plate  patented  by  Mr.  Gilbert,  of  New 
Haven.  The  cavity  now  generally  employed  is  formed  on  the  median 
line,  either  far  back  for  fnll  plates  (Fig.  615),  or  immediately  behind 
the  alveolar  ridge  for  some  partial  plates.  Dr.  Flagg  adds  two  lateral 
cavities  on  the  slope  of  the  palate,  with  a  view  to  prevent  the  plate 
from  rocking,  and  to  give  it  increased  stability.  Dr.  Levett's  lateral 
cavities  are  placed  directly  upon  the  ridge  (Fig.  616).  With  this  brief 
history  of  cavity  plates,  we  shall  proceed  to  give  a  concise  description 
of  the  manner  of  constructing  them.  The  following  is  the  mode  of 
construction  of  Dr.  Cleaveland's  cavity  plate,  which,  for  reasons  given 
below,  is  now  seldom  used. 

A  metallic  die  and  counter-die  having  been  obtained,  a  plate  is 
swaged,  covering  the  entire  alveolar  border  and  extending  back  as  far 
as  the  line  P  (Fig.  613).  This  done,  it  is  placed  in  the  mouth,  and 
if  found  to  be  accurately  adapted  to  the  parts,  it  is  removed  ;  a  half- 
round  gold  wire,  about  the  size  of  a  common  knitting  needle,  is  then 

Fig.  615.  Fig.  616. 


soldered  to  the  lingual  side  of  the  plate,  enclosing  a  space  shaped 
somewhat  as  is  shown  in  Fig.  615,  varying  in  size  and  form  with  the 
differences  in  shape  and  size  of  the  plate  and  alveolar  ridge.  The 
part  within  the  wire  is  nest  cut  out  with  punch-forceps,  or  saw,  and 
the  j^late  placed  on  the  model ;  a  piece  of  wax,  about  a  tenth  or 
twelfth  part  of  an  inch  in  thickness,  having  a  circumference  one-fourth 
greater  than  the  hole  in  the  plate,  is  then  placed  over  the  opening, 
extending  a  short  distance  beyond  the  wire  on  every  side.  The  wax 
at  the  outside  is  brought  to  a  thin  edge,  and  is  also  made  thinner  in 
the  centre  than  where  it  covers  the  wire  surrounding  the  opening  in 
the  plate.  From  this  model  with  plate  and  wax  upon  it,  die  and 
counter-die  are  obtained  with  which  to  swage  a  thin  plate  of  gold, 
large  enough  to  cover  the  wax ;  its  edge  is  chamfered  off,  and  it  is 
then  soldered  to  its  place  on  the  plate,  where  it  may  be  secured  during 
soldering,  either  by  iron  wire  clamps  or  by  gold  rivets.  A  sectional 
view  of  the  cavity  is  represented  in  Fig.  617  A.     The  Cleaveland 


Xy< 


804  MECHANICS. 

cavity  causes  the  plate  to  adhere  with  great  tenacity;  as,  from  its 
shape,  it  is  impossible  for  the  mucous  membrane  entirely  to  fill  it;  the 
traction  of  this  cavity  is  constant.  A  serious  objection  to  its  use  is 
the  great  irritation  it  excites  in  the  mucous  membrane,  in  the  majority 
of  cases. 

The  simpler  cavity  plate  used  by  Dr.  Jahial  Parmly,  of  New  York, 
and  patented  by  Mr.  Gilbert,  of  New  Haven,  may  be  formed  with 
nearly  as  much  ease  as  a  plain  plate.  Fig.  617  B  represents  a  sec- 
tional view  of  this  description  of  plate.    If  it  is  desired  to  have  lateral 

cavities,  three  pieces  of  wax  are 
placed  on   the  plaster  model — 
A     one  in  the  centre,  as  already  de- 
scribed, and  one  on  the  slope  of 
'  g     the  alveolar  ridge,  on  each  side. 
When  it  is  desirable  to  make  a 
fQ      cavity  with  sharply  defined  bor- 
der, D,  a  second  plate,  a  little 
,  pj     larger  than  the  projection,  should 
ba  swaged  over  the  base  plate. 
y.  -,  From  the  base  plate  the  projec- 

tion is  to  be  cut  out,  and  the 
smaller  plate  soldered  over  the  opening.  For  hard  mouths,  the  thick- 
ness of  the  main  plate  will  give  sufiicient  depth  of  cavity,  C ;  in  this 
case  no  projection  is  to  be  placed  on  the  model. 

Should  the  usual  method  of  exhausting  air  from  these  cavities  be 
thought  insufficient,  the  valve  of  Dr.  Dwindle  (Fig.  617  V)  may  be 
inserted  in  the  plate  covering  the  cavity.  The  conical  portion  is 
neatly  fitted  by  grinding ;  the  stem  is  soldered  to  a  spring  on  the  pala- 
tine surface,  A  valve  of  easier  construction  is  given  at  V;  a  small 
rubber  pad  acts,  by  the  spring,  upon  the  outside  of  the  hole.  The  size 
of  valves  and  thickness  of  plate  are  exaggerated,  the  better  to  illustrate 
the  details  of  construction.  By  means  of  either  of  these  valves,  a 
vacuum  may  be  created,  which  will  draw  with  great  force  upon  the 
membrane  over  the  cavity. 

The  forms  B  and  D,  Fig.  617,  necessitate  a  prominence  in  the  die, 
which  is  variously  formed.  When  the  die  is  made  by  sand  moulding, 
a  corresponding  one,  formed  of  wax,  lead,  tin,  or  plaster,  is  put  on  the 
model ;  a  die  made  by  dipping,  or  pouring,  or  by  the  fusible  metal 
process  requires  plaster.  Dies  made  by  pouring  into  the  impression 
require  the  cavity  to  be  cut  out  in  the  impression  itself.  A  variety  of 
shapes  in  tin  and  lead  are  furnished  by  the  depots,  chiefly  for  vulcanite 
work  ;  but  they  may  be  used  also  for  the  sand  moulding  model.  Plates 
made  by  the  metallo-plastic  processes  require  plaster  prominences. 


RETENTION  OF  BASE  PLATES. 


805 


The  size,  depth,  form  and  position  of  the  cavity  are  important  con- 
siderations. In  size,  it  must  be  proportioned  to  the  plate.  Fig.  618 
gives  a  fair  average  size,  and  is  excellent  in  form,  except  that  it  is 
unnecessarily  pointed  ;  all  angles  and  sharp  corners  should  be  avoided, 
and  fanciful  shapes  are  aesthetic  blun- 
ders ;  the  form  should  appear  to  grow 
out  of  some  necessity ;  and  hence  it 
should  be  modified  to  suit  the  form  of 
plate.  Shallow  cavities  may  be  larger 
than  deep  ones ;  partial  pieces  usually 
have  a  cavity  larger  in  proportion. 

Fig.  619  represents  the  usual  forms 
of  vacuum  cavities,  which  may  be 
metal,  such  as  block  tin,  that  will  not 
discolor  the  rubber ;  vacuum  cavities 
made  of  sheet  lead  are  objectionable, 
on  that  account. 


''Wuuju — ' — ^- 


FiG.  619. 


In  depth,  the  cavity  must  vary  with  the  softness  of  the  membrane. 
If  soft,  it  quickly  fills  a  shallow  cavity,  and  is  less  liable  to  injury  by 
a  deep  one.  Sharp-edged  cavities  fill  less  quickly  than  round-edged 
ones.  They  may  vary  in  thickness  from  No.  14  to  No.  24,  gauge 
plate,  page  702.  When  the  cavity  is  designed,  after  a  temporary 
retaining  power,  to  act  permanently  in  relieving  pressure  on  central 
hard  parts,  it  should  be  very  shallow.  When,  in  very  flat  mouths,  it 
is  proposed  to  prevent  lateral  motion  by  the  mucous  prominence,  the 
cavity  should  be  deeper.  Extreme  depth,  with  a  view  to  keep  up 
constant  action,  makes  a  most  unsightly  piece,  and  injures  the  mouth. 

As  to  position,  there  would  seem  to  be  much  difference  of  opinion, 
if  we  judge  by  the  various  points  selected.  We  have  never  had  but 
one  opinion  on  this  subject,  and  that  is  in  favor  of  the  central  cavity. 
The  cavity  resists  the  greatest  force  of  displacement  when  applied  at 
right  angles ;  as  this  force  is  always  nearly  or  quite  vertical,  it  follows 
that  the  most  effective  cavities  are  horizontal ;  hence,  they  should  only 
be  on  the  roof  of  the  palate,  and  limited  to  its  level  portion.  Cavities 
covering  the  rugae,  or  sloping  walls  of  the  palate,  act  at  disadvantage. 


806  MECHANICS. 

Again,  after  the  cavity  ceases  to  act,  its  secondary  use  in  relieving 
pressure  can  be  available  only  in  this  position.  The  very  worst  posi- 
tion for  a  cavity  is  on  the  ridge  of  either  upper  or  lower  jaw.  Firm 
pressure  on  the  ridge  is  one  of  the  most  important  elements  of  stability 
in  a  plate.  It  is  difficult  to  comprehend  what  compensation  for  the 
loss  of  this  is  found  in  the  cavity. 

Partial  plates  require,  when  the  cavity  is  used,  a  modification  of 
form  to  enable  the  cavity  to  be  placed  on  the  roof  of  the  palate.  Yet 
the  shapes  elsewhere  given  may  be  used  in  connection  with  Flagg's 
lateral  cavities  as  represented  by  the  oval  in  Fig.  620.  If  no  stays 
can  be  used,  as  in  a  piece  of  artificial  bicuspids  and  molars  wnth 
natural  incisors  and  canines,  a  central  or  two  lateral  sharp-edged 
cavities  may  be  of  service,  to  prevent  lateral  motion.  In  all  other 
partial  cases  stays  may  be  used ;  these,  combined  with  accurate  fitting, 
will  give  as  firm  a  piece  as  any  form  of  cavity.  The  vacuum  cavity 
may  also  be  formed  in  the  impression,  by  adapting  a  form  of  wax  to 
the  roof  of  the  mouth,  in  the  proper  position,  before  inserting  the  cup. 

Fig.  620.  Fig.  621. 


Dr.  C.  H.  Land  has  recently  suggested  a  vacuum  cavity  pattern 
(Fig.  621),  which  is  claimed  to  be  of  such  a  form  as  to  secure  the 
greatest  advantage  from  atmospheric  pressure,  without  injury  to  the 
mouth  ;  also  to  serve  as  a  relief  to  the  hard  portions  of  the  arch,  by 
being  of  sufficient  depth  to  allow  for  continued  absorption  of  the 
alveolar  ridge  in  the  case  of  first  sets ;  it  is  also  claimed  that  its  shape 
avoids  interference  with  the  organs  of  speech. 

The  processes  heretofore  described,  and  the  rules  laid  down,  have 
been  considered  mainly  in  their  relation  to  artificial  teeth  mounted 
upon  GOLD  PLATE  by  the  operation  of  soldering.  But  other  metals 
may  be  swaged  by  the  same  processes,  as  platinum,  aluminum,  and 
silver. 

Silver  is  the  least  valuable  of  these,  and  has  nothing  to  recommend 
it  except  its  cheapness,  in  which  questionable  merit  it  has  aluminum 
and  vulcanite  as  its  competitors  ;  and  hence  it  is  now  not  very  much 


EETEXTIOX  OF  BASE  PLATES.  807 

used.  It  is  manipulated  in  all  respects  like  gold  ;  except  in  the  oper- 
ations of  refining  by  acids,  the  composition  of  solders  used,  and  the 
care  necessary  in  soldering,  from  the  fusibility  of  the  plate.  As  every 
good  dental  mechanic  values  his  work  far  beyond  the  mere  cost  of 
material,  we  can  in  no  case  recommend  silver  as  a  base  plate.  Patients 
who  can  pay  the  greater  cost  of  the  work,  can  pay  the  lesser  cost 
of  the  gold  ;  and  dentists  who  can  afford  to  give  the  work,  can  give 
the  ffold  still  more  easilv.  We  assume  that  he  who  o-ives  work  gives 
his  best ;  otherwise  he  gives  away  his  reputation  also — an  excess  of 
generosity  not  to  be  commended. 

Aluminum  can  be  rolled  into  plate,  and  swaged.  It  requires  extreme 
care  in  annealing,  but  makes  a  rigid,  strong  and  very  light  plate.  It- 
does  not  withstand  the  buccal  secretions  as  well  as  twenty-carat  gold, 
but  is  nearly  or  quite  as  good  as  eighteen-carat  gold.  The  obstacle 
to  its  general  use  lies  in  the  fact  that,  as  yet,  there  is  no  good  solder 
for  it.  Hence  it  is  necessary  to  attach  the  teeth  by  vulcanite.  This 
can  be  very  successfully  done,  as  vulcanized  rubber  adheres  more  closely 
to  this  metal  than  to  any  other,  excepting,  perhaps,  pure  gold  or  pure 
platinum.  The  process  will  be  described  in  the  section  on  Vulcanite ; 
it  is  equally  applicable  to  twenty-carat  gold  and  to  platinum,  but  not 
at  all  to  silver. 

Platinum,  if  alloyed  with  five  to  ten  per  cent,  of  gold,  has  stiffness 
sufficient  to  be  used  as  a  base  plate,  in  the  manner  previously  given  for 
gold.  As  it  has  no  advantage  over  gold  when  used  in  this  way,  its 
less  cost  is  not  a  sufficient  offset  to  the  inconveniences  attending  its  use 
and  to  the  color,  which  is  so  objectionable  to  most  persons  that  they 
are  unwilling  to  pay  as  much  as  for  the  same  work  in  gold.  Platinum 
has,  however,  one  remarkable  property  possessed  by  no  other  used  by 
dentists  except  palladium,  which  is  now  scarcely  at  all,  if  ever,  used; 
it  cannot  be  fused  in  the  highest  heat  of  the  forge  or  porcelain-baking 
furnace.  Hence  it  is  the  only  metal  used  for  the  metallic  pins  and 
other  fastenings  inserted  into  porcelain  teeth  ;  requiring  for  its  fusion 
the  flame  of  the  oxyhydrogen  blowpipe.  It  is  also  the  only  metal  used 
in  a  remarkably  beautiful  style  of  work  known  as  the  Continuous 
Gum  Work,  which  forms  the  subject  of  the  next  section. 

TEETH   SET   UPOX   PLATIXA   WITH   A   COXTINUOrS   ARTIFICIAL    GUM. 

The  idea  of  uniting  porcelain  teeth  to  a  metallic  base  by  means  of 
a  fusible  silicious  composition  originated  in  France,  where  the  method 
has,  to  some  extent,  been  practiced  since  1820.  But  Dr.  Fitch,  who 
spent  much  time  in  Paris,  and  was  well  acquainted  with  the  French 
method  and  Delabarre's  formula,  states,  that  the  latter  had  never  per- 
fected his  reciiDCS,  or  brought  them  into  practical  use.    The  composition 


808  MECHANICS. 

employed  there,  judging  from  the  specimens  which  the  author  has  in 
his  possession,  cannot  be  used  in  connection  with  porcelain  teeth  con- 
taining as  large  a  proportion  of  feldspar  as  those  manufactured  in  this 
country.  Delabarre's  compound,  according  to  Dr.  Locke,  required 
3761°  Fahrenheit  to  fuse  it  completely.  Below  this,  it  fused  imper- 
fectly, and  was  found  too  fragile. 

The  process  now  known  as  the  Continuous  Gum  consists  essentially 
of  a  silicious  paste,  similar  (except  more  fusible)  in  composition  to  that 
of  which  the  teeth  are  made,  which  is  applied  around  the  bases  and 
fastenings  of  teeth  previously  soldered  upon  a  plalje  of  purest  platina, 
and  then  fused  at  a  temperature  of  about  2200°  Fahrenheit.  It  takes 
its  name  from  the  fact  that,  unlike  blocks  or  single  gum  teeth,  it  presents 
an  unbroken  continuous  gum  outside  the  alveolar  ridge,  as  is  shown 

in  Fig.  622,    It  is  applied  in  two  layers — 
±16.  622.  ^  yellowish-white  body,  giving  the  general 

contour  of  the  gum,  and  an  enamel,  to 
produce  that  correct  imitation  of  the  nat- 
ural gum,  for  which  nothing  but  ceramic 
materials  have  as  yet  been  found  suitable. 
Dr.  Allen  covers  with  the  same  material 
the  entire  lingual  surface  of  the  plate, 
and  also  certain  projections  outside  of  the  molars  and  above  the 
cuspids,  designed  by  him  for  the  restoration  of  the  natural  fullness  of 
the  face. 

This  falling  in  of  the  features  is  due  to  the  absorption  of  the  alveolar 
ridge,  and  cannot  be  fully  restored  by  an  artificial  set  of  teeth,  as 
usually  made ;  since,  if  the  molars  were  set  out  to  the  original  width  of 
the  teeth,  the  force  of  mastication  would  fall  outside  the  absorbed 
alveolus  and  render  it  practically  useless.  Dr.  Allen's  device  corrects 
this  sinking,  under  the  malar  prominence  of  the  superior  maxilla  and 
in  the  canine  fossa,  and  thus  greatly  aids  in  the  restoration  of  the  face 
to  its  original  appearance. 

This  process  was  patented  by  Dr.  John  Allen,  in  1851  ;  but  the 
priority  of  invention  was  contested  by  Dr.  William  H.  Hunter,  in  a 
suit,  the  progress  and  result  of  which  are  well  known  to  all  readers  of 
the  journals.  Dr.  Allen  surrendered  his  patents  of  1851,  owing  to 
certain  defects  in  the  same,  and  in  1856  a  new  patent  was  issued  to 
him  for  the  process  as  then  improved.  The  process  is  very  generally 
known  as  "Allen's  Continuous  Gum,"  the  materials  for  which,  as  pre- 
pared by  him,  can  be  obtained  at  all  the  depots.  The  formulae  given 
in  this  chapter  are  those  of  Dr.  Hunter,  and  the  earlier  ones  of  Dr. 
Allen.  As  all  such  materials  are  more  perfectly  prepared  on  a  large 
scale,  we  think  it  much  better  to  purchase  than  to  make  them. 


RETENTION  OF  BASE  PLATES.  809 

A  "  continuous-gum  "  piece,  made  in  the  most  perfect  manner,  is 
only  surpassed  in  point  of  beauty  by  the  occasional  productions  of  a 
very  few  block  carvers ;  but  so  rare  are  these  specimens  of  perfection 
in  block  work,  that  we  may  safely  say  of  the  continuous-gum  work 
that,  when  properly  made,  it  is  the  most  beautiful,  as  it  certainly  is 
the  purest  and  sweetest,  that  can  be  worn  in  the  mouth,  so  long  as  the 
porcelain  covering  maintains  its  integrity.  As  regards  this  important 
point,  durability,  our  own  experience  does  not  permit  us  to  speak  con- 
fidently. It  was  thought,  when  this  method  of  mounting  artificial 
teeth  was  first  adopted,  that  the  springing  of  the  plate  in  the  act  of 
mastication  would  cause  the  gum  to  crack  and  scale  off";  which  did 
occur  in  a  large  proportion  of  the  cases.  Although  the  injury  could 
be  repaired  by  replacing  the  loss  with  fresh  composition,  and  fusing  it 
to  the  fractured  edges  of  the  remaining  portions  and  to  the  plate,  yet 
this  formed  a  very  serious  objection  to  its  use.  But  later  improve- 
ments in  the  strength  of  the  compound,  and  also  in  the  rigidity  of  the 
plate  and  soldered  backings,  have  so  far  corrected  this  evil,  that  it  is 
perhaps  no  more  liable  to  accident  while  in  the  mouth  than  any  other 
kind  of  work.  But,  out  of  the  mouth,  its  weight  renders  it  peculiarly 
exposed  to  accident ;  a  fall  is  almost  certain  to  break  one  or  more 
teeth,  or  crack  the  silicious  covering  of  the  plate.  Hence,  it  is  neces- 
sary to  impress  upon  the  patient  the  great  importance  of  the  most 
careful  handling. 

By  uniting  the  teeth  to  each  other  near  their  base,  and  to  the  plate, 
with  a  glazed  porcelanic  material,  the  cleanliness  of  the  substitute  is 
most  perfectly  secured  ;  as  all  the  openings  beneath  and  around  them 
are  completely  closed,  excluding  the  secretions  of  the  mouth  and  par- 
ticles of  food,  which  have  no  affinity  for  or  action  upon  the  porcelain. 
In  this  respect,  they  are  superior  to  the  most  perfectly  mounted  block 
teeth ;  while  the  labor  of  putting  up  a  set  of  the  former  can  be  per- 
formed in  half  the  time  required  for  making  and  mounting  a  set  of 
the  latter.  A  person  who  can  mount  single  teeth  well  may  acquire  a 
knowledge  of  this  method,  with  proper  instruction,  in  a  few  weeks ; 
although  much  of  the  peculiar  talent  required  in  block  carving  is 
needed  in  arranging  the  teeth  and  shaping  the  gum  for  this  process, 
the  details  are  comparatively  simple,  and  may  soon  be  taught.  Of 
course,  much  practice  will  be  required,  especially  in  the  management 
of  the  furnace  heats.  The  necessity  for  such  practice,  to  enable  one 
successfully  to  manage  the  furnace,  is  the  chief  obstacle  to  its  casual 
use  by  the  practitioner.  Unless  he  makes  it  a  specialty,  and  does  all 
his  own  work,  and  some  for  his  neighbors,  he  will  be  certain  to  meet 
with  many  discouraging  failures  in  the  final  process  of  baking  an 
otherwise  perfectly  constructed  piece. 


810  MECHANICS. 

We  therefore  advise  the  dentist  to  swage  the  platina  plate,  select  and 
arrange  and  articulate  the  teeth ;  for  no  one  should  be  so  competent  to 
this  as  the  one  whose  intercourse  with  the  patient  enables  him  to  judge 
exactly  what  form,  color,  and  arrangement  of  teeth  are  best  suited  to 
the  case;  and  only  he  can  decide  upon  the  correctness  of  the  fit  of  the 
plate.  But  when  all  this  is  done,  the  piece  should  be  securely  packed 
and  sent,  by  express  or  mail,  to  Dr.  John  Allen,  of  New  York,  or  some 
experienced  worker  in  the  continuous  gum.  The  piece  will  be  returned 
with  the  plate  unchanged  in  shape,  and  the  porcelain  work  executed  in 
such  style  as  can  be  reached  only  by  constant  practice  and  familiarity 
with  the  special  details  of  this  work. 

The  artificial  gum  consists,  as  we  have  stated,  of  two  parts ;  the  first 
is  termed  the  base  or  hodxj,  as  this  constitutes  the  principal  part  of  the 
cement,  and  is  used  for  filling  in  between  the  teeth  and  building  up  the 
gum  on  the  plate ;  the  other  is  gum  enamel.  The  materials  employed 
by  Dr.  Hunter,  in  the  composition  of  his  compounds,  are  silex,  fused 
spar,  calcined  borax,  caustic  potash  and  asbestos.  The  silex  and  spar 
should  be  of  the  clearest  and  best  quality,  and  ground  very  fine. 
The  asbestos  should  be  freed  from  talc  and  other  foreign  substances, 
and  reduced  to  a  fine  powder.  He  gives  the  following  formulije  and 
directions. 

Flux.— Take  of  silex,  8  oz. ;  calcined  borax,  4  oz. ;  caustic  potash, 
1  oz.  The  potash  is  first  ground  fine  in  a  wedgewood  mortar,  and  the 
other  materials  gradually  added  until  they  are  thoroughly  mixed. 
Line  a  Hessian  crucible  (as  white  as  can  be  had)  with  pure  kaolin,  fill 
with  the  mass,  and  lute  on  a  cover  of  a  piece  of  fire-clay  slab  with 
the  same.  Expose  to  a  clear,  strong  fire,  in  a  furnace,  with  coke  fuel, 
for  about  half  an  hour,  or  until  it  is  fused  into  a  transparent  glass, 
which  should  be  clear  and  free  from  stain  of  any  kind.  This  is  broken 
and  ground  until  it  will  pass  a  bolting  sieve. 

Granulated  Body. — Spar,  3  oz. ;  silex,  1^  oz. ;  kaolin,  }  oz. ; 
completely  fused.  Break  and  grind  so  that  it  will  pass  through  a 
wire  sieve  No.  50,  and  again  sift  off"  the  fine  particles,  which  pass 
through  No.  10  bolting  cloth,  which  leaves  it  in  grains  about  the  size 
of  the  finest  gunpowder.  It  may  be  made  of  hard  porcelain,  fine  china, 
or  wedgewood  ware. 

Body. — Take  flux,  1  oz. ;  asbestos,  2  oz. ;  grinding  together  very 
finely,  completely  intermixing.  Add  granulated  body,  1*  oz. ;  and 
mix  with  a  spatula,  to  prevent  grinding  the  granules  of  body  any 
finer. 

Enamels. — No.  1.  Flux,  1  oz. ;  fused  spar,  1  oz.;  English  rose  red, 
40  grains.  Grind  English  rose  red  extremely  fine,  in  a  mortar,  and 
gradually  add  the  flux,  and  then  the  fused  spar,  grinding  until  the 


RETENTION  OF  BASE  PLATES.  811 

ingredients  are  thoroughly  incorporated.  Cut  down  a  large  Hessian 
crucible,  so  that  it  will  slide  into  the  muffle  of  a  furnace,  line  with  a 
mixture  of  equal  parts  silex  and  kaolin,  put  in  the  material,  and  raise 
the  heat  to  the  point  of  vitrification,  not /u^ion,  then  withdraw  from  the 
muffle.  The  result  will  be  a  red  cake  of  enamel  which  will  easily 
leave  the  crucible,  which,  after  removing  any  adhering  kaolin,  is  to  be 
broken  down  and  ground  tolerably  fine.  It  may  now  be  tested,  and, 
if  of  too  strong  a  color,  tempered  by  the  addition  of  covering.  This 
is  the  gum  which  flows  at  the  lowest  heat,  and  is  never  used  before 
soldering. 

Xo.  2.  Flux,  1  oz. ;  fused  spar,  2  oz. ;  English  rose  red,  60  grains. 
Treat  the  same  as  No.  1.  This  is  a  gum  intermediate,  and  is  used  upon 
platina  plates. 

No.  3.  Flux,  1  oz. ;  fused  spar,  3  oz. ;  English  rose  red,  80  grains. 
Treat  as  the  above.  This  gum  is  used  in  making  pieces  intended  to 
be  soldered  on,  either  in  full  arches  or  in  the  sections  known  as  block 
worlc.  It  is  not  necessary  to  grind  veiy  fine,  in  preparing  the  above 
formulae. 

CoYEEixG. — What  is  termed  covering  is  made  by  the  same  formulse 
as  for  the  enamel,  omitting  the  English  rose  red.  Being  without  any 
coloring  whatever,  it  is  used  for  tempering  the  above  enamels  when 
too  highly  colored,  which  may  be  done  by  adding,  according  to  circum- 
stances, from  one  to  six  parts  of  covering  to  two  of  enamel,  thus  pro- 
curing the  desired  shade.  When  it  is  to  be  used  for  covering  the  base 
prior  to  applying  the  enamel,  it  may  be  covered  with  titanium,  using 
from  two  to- five  grains  to  the  ounce. 

Investient. — Take  two  measures  of  white  quartz  sand,  mix  with 
one  measure  of  plaster-of-Paris,  using  just  enough  water  to  make  the 
mass  plastic,  and  apply  quickly.  The  slab  on  which  the  piece  is  set 
should  be  saturated  with  water,  to  keep  the  material  from  setting  too 
soon,  and  that  it  may  unite  with  it. 

Memoeaxda. — In  preparing  material,  always  grind  dry,  and  use 
the  most  scrupulous  cleanliness  in  all  the  manipulations.  In  all  cases 
where  heat  is  applied,  it  should  be  raised  gradually  from  the  bottom 
of  the  muffle,  and  never  run  into  a  heat.  Where  it  is  desired  to 
lengthen  any  of  the  teeth,  or  to  mend  a  broken  tooth,  it  may  be  done 
with  covering,  pi'operly  colored  with  platina,  cobalt,  or  titanium. 

In  repairing  a  piece  of  work,  wash  it  with  great  care,  using  a  stiff 
brush  and  pulverized  pumice  stone.  Bake  over  a  slow  fire,  to  expel 
all  moisture,  and  wash  again,  when  it  will  be  ready  for  any  new  appli- 
cation of  the  enamel.  Absorption,  occurring  after  a  case  has  been 
some  time  worn,  by  allowing  the  jaws  to  close  nearer,  causes  the  lower 
jaw  to  come  forward  and  drive  the  upper  set  out  of  the  mouth.     By 


812  MECHANICS. 

putting  the  covering  on  the  grinding  surfaces  of  the  back  teeth  in 
sufficient  quantity  to  make  up  the  desired  length,  this  difficulty  may 
be  to  some  extent  remedied. 

Any  alloy  containing  copper  or  silver  should  not  be  used  for  solder 
or  plate,  if  it  is  intended  to  fuse  a  gum  over  the  lingual  side  of  the 
teeth,  as  it  will  surely  stain  the  gum.  Simple  platinum  backs  alone  do 
not  possess  the  requisite  stiffbess,  and  should  always  be  covered — on 
platinum  with  the  enamel,  and  on  gold  with  another  gold  back.  In 
backing  the  teeth,  lap  the  backs,  or  neatly  join  them  up  as  far  as  the 
lower- pin,  in  the  tooth,  and  higher  if  admissible,  and  in  soldering  be 
sure  to  have  the  joint  so  made  perfectly  soldered. 

The  compositions  originally  employed  by  Dr.  Allen  consist  of — 
Body  :  Silex,  2  oz. ;  flint  glass,  1  oz. ;  borax,  1  oz. ;  wedgewood  ware, 
IJ  oz. ;  asbestos,  2  drachms;  feldspar,  2  drachms;  kaolin,  1  drachm. 
Enamel:  Feldspar  ?  oz. ;  white  glass,  1  oz. ;  and  oxide  of  gold,  li 
grains.  Since  the  publication  of  the  early  editions  of  this  work,  great 
improvements  have  been  made  by  Dr.  Allen  in  the  composition  and 
preparation  of  both  the  body  and  gum  enamel,  which  are  furnished 
by  the  manufacturers,  and  may  be  obtained  at  any  of  the  dental 
depots,  at  a  very  moderate  price. 

The  metals  which  may  be  employed  for  the  base  in  this  method  of 
mounting  artificial  teeth  are  platinum  or  pure  palladium.  The  common 
commercial  article  of  palladium  is  not  pure,  and  is  never  used  in  this 
country.  Platinum,  alloyed  with  from  one  to  ten  per  cent,  of  pure  gold, 
may  also  be  used  ;  but  it  is  objectionable,  from  its  liability  to  spring  or 
warp.  It  makes  a  stifier  plate,  and  so  far  has  the  advantage  over  pure 
platinum,  but  for  the  reason  given  the  purest  metal  should  be  selected. 
Because  of  its  softness,  it  must  be  used  thicker  than  gold  plate.  The 
process  of  swaging  the  plate  is  the  same  as  before  given.  It  must  be 
often  annealed,  and  gradually  carried  into  any  deep  depressions,  for 
its  softness  makes  it  more  liable  than  gold  to  be  torn,  made  thin,  or 
punched  through.  A  narrow  rim,  partially  turned  up,  is  to  be  left 
around  the  outside.  The  process  of  articulating,  etc.,  is  similar  to  that 
for  gold.  In  adjusting  the  teeth,  accurate  grinding  is  unnecessary  ; 
but  each  tooth  should  touch  the  plate.  Part  of  each  backing  should 
lap  over  the  adjoining  ones,  and  behind  the  six  front  teeth  should 
also  be  lapped  over  an  additional  narrow  band,  to  give  greater  rigidity 
to  the  plate.  In  this  process  there  is  great  opportunity  to  give  to  the 
teeth  that  irregularity  of  arrangement  which  forms  one  of  the  charac- 
teristics of  natural  teeth  ;  neglect  of  which  gives  to  many  otherwise 
excellent  pieces  of  work  an  unnatural,  artificial  appearance,  that 
shows  great  deficiency  in  the  cultivation  of  dental  cesthetics. 

Before  backing  the  teeth  the  piece  may  be  tried  in  the  mouth  and 


RETENTION  OF  BASE  PLATES. 


813 


any  inaccuracy  of  articulation  readily  corrected ;  careful  articulation 
makes  this  trial  unnecessary  ;  but  if  from  any  causes  changes  are 
found  on  trial  to  be  needed,  they  can  be  made  more  readily  in  this 
work  before  the  gum  is  added,  than  in  any  other  ;  since  no  joints  or 
neat  fitting  to  the  plate  are  disturbed  by  changes  in  the  position  of 
a  tooth.  After  they  are  backed,  the  piece  should  be  set  in  a  mixture 
of  plaster  and  asbestos  (Dr.  Allen  prefers  asbestos  to  sand),  resting  on 
a  muffle  slide,  and  coming  up  around  the  outside  of  the  teeth,  to  keep 
them  in  place.  The  solder  used  must  contain  no  trace  of  either  silver 
or  copper,  as  they  will  stain  the  gum  enamel  and  body ;  but  must  be 
either  pure  gold,  or  alloyed  with  about  five  per  cent,  platina.     Borax 


Fig.  623. 


Fig.  624. 


may  be  used,  not  in  this  case  as  a  flux — for  where  there  is  no  oxidation 
no  flux  is  required — but  to  tack  the  pieces  of  solder  to  place  until 
ready  to  flow.  The  slide  is  then  gradually  carried  into  the  muffle,  and 
the  whole  piece  raised  to  the  melting  point  of  the  solder. 

Figs.  623  and  625  represent  two  of  the  most  approved  forms  of 
furnaces,  the  latter  being  the  device  of  Dr.  Tees. 

Fig.  624  represents  Verrier's  furnace  for  continuous-gum  work.  It 
is  operated  with  the  regular  house  supply  of  gas,  aided  by  the  blast 
from  the  foot  blower  (Fig.  566).  It  is  claimed  that  this  furnace  will 
fuse  gum  body  or  enamel  in  from  five  to  ten  minutes. 


814  MECHANICS. 

The  rules  for  the  management  of  the  heat  are  the  same  as  hereafter 
given  for  block  work.  The  heat  required  for  this  is  not,  however,  so 
great  as  that  required  in  block  work;  the  gold  and  the  continuous- 
gum  materials  fusing  at  about  2200°  Fahrenheit. 

Fig.  625. 


Having  thus  soldered  and  cooled  off  the  piece  very  gradually,  it 
must  be  thoroughly  washed,  so  as  to  remove  every  particle  of  invest- 
ment. Then,  with  a  camel's-hair  brush  and  small  knife,  such  as  are 
used  in  block  carving,  the  spaces  between  the  teeth  and  plate  are  to  be 


RETENTION  OF  BASE  PLATES.  815 

perfectly  filled  with  a  finely  compacted  paste  of  body  and  rain  water. 
The  paste  nuist  be  applied  very  moist,  so  as  to  exclude  the  air  and 
ran  into  all  the  spaces  ;  then  dried  with  cloth  or  bibulous  paper,  and 
compressed  with  the  knife.  If  the  lingual  surface  of  the  plate  is  to  be 
covered,  this  should  be  made  rough  by  soldering  small  clippings  of 
platina  over  it,  at  the  time  the  teeth  are  soldered.  The  natural  rugpe 
of  the  palate  should  be  imitated  in  the  thin  layer  of  body  which  is 
applied. 

The  work  must  then  be  slowly  and  thoroughly  dried,  and  the  piece 
put  on  a  slide  with  the  coronal  ends  of  the  teeth  downward,  and 
imbedded  to  the  depth  of  an  eighth  of  an  inch  in  a  thick  batter  of 
plaster  and  asbestos.  But  if  the  teeth  are  very  securely  soldered,  it 
will  be  best  to  flow  the  body  with  the  plate  resting,  teeth  upward,  on 
the  plaster  and  asbestos  model  on  which  the  soldering  was  done.  The 
slide  is  then  gradually  introduced  into  the  mufile,  and  subjected  to  a 
heat  sufficiently  high  to  fuse  the  compound — say,  twenty-two  hundred 
and  fifty  degrees.  It  is  then  withdrawn  slowly,  and  completely  cooled. 
Usually  there  will  be  cracks  and  flaws  which  need  filling  with  paste. 
The  outside  rim  is  also  to  be  turned  down  over  the  edge  of  the  body 
with  hammer  and  pliers,  and  any  defects  at  this  point  filled  up ;  then 
heat  a  second  time,  with  the  same  care  as  at  first. 

The  piece,  now  ready  for  enameling,  should  present  a  semi-vitrified 
appearance  ;  if  too  highly  glazed,  it  is  too  much  done,  and  the  enamel 
will  not  take  so  firm  a  hold  ;  if  too  dull  looking,  it  is  not  sufficiently 
baked,  and  will  be  deficient  in  strength.  The  enamel  must  be  applied 
moist,  and. is  best  put  on  with  a  brush ;  much  plastering  with  the  knife 
makes  it  apt  to  fly  off"  in  baking,  and  for  the  same  reason  it  must  be 
heated  very  gradually.  The  layer  of  enamel  should  be  thin  and  irreg- 
ular, the  yellowish  white  of  the  body  showing  more  or  less  through  it, 
so  as  to  give  the  variations  of  tint  observed  in  the  natural  gum.  If  a 
thick  and  even  layer  is  applied,  the  result  will  be  an  unnatural 
uniform  color,  which  will  destroy  much  of  the  peculiar  beauty  of  this 
work. 

The  greatest  care  is  necessary,  in  applying  the  paste,  to  remove 
every  particle  from  the  parts  of  the  teeth  and  plate  which  are  not  to 
be  covered,  as  it  adheres  with  great  tenacity  and  roughness,  and  dis- 
figures these  parts.  Much  experience  is  also  necessary  in  determining 
the  exact  heat  necessary  to  develop  the  full  beauty  and  strength  of 
the  work.  Repeated  heatings,  either  for  the  first  making  or  for 
repairs,  do  not  injure  the  plate  or  teeth,  provided  proper  care  is  taken 
to  heat  and  cool  gradually ;  and  provided,  in  case  of  repair,  the  piece 
is  thoroughly  cleaned  in  strong  soda,  to  remove  all  trace  of  the  buccal 
secretions. 


816  MECHANICS. 

This  work  is  peculiarly  adapted  to  full  lower  dentures.  The  prin- 
ciples of  construction  are  precisely  the  same,  only  the  plate  should  be 
very  heavy,  and  the  extra  band  behind  the  six  or  eight  front  teeth 
very  thick  and  strong.  Many  use  it  for  partial  cases  ;  for  which,  ho\y- 
ever,  the  author  does  not  regard  it  as  well  suited.  The  three  distin- 
guishing advantages  of  the  continuous-gum  work  are  its  ready  adapta- 
bility to  every  variety  in  shape  of  gum  and  arrangement  of  teeth,  its 
extreme  beauty,  and  its  great  cleanliness  ;  its  three  disadvantages  are 
its  weight,  its  liability  to  be  broken  by  accident,  and  inapplicability  to 
partial  cases. 


CHAPTER  XIV. 

MOULDED   PLATES   OF   PLASTIC    MATERIALS. 

IN  the  classification  of  operations  for  the  Replacement  of  Teeth, 
given  on  pages  625-7,  difference  in  the  order  of  these  operations 
was  made  the  groundwork  of  a  division  of  all  base  plates  into  two 
classes :  Swaged  and  Plastic.  In  describing,  up  to  the  point  of 
completion  of  the  model,  the  operations  common  to  both  classes,  the 
modifying  requirements  of  each  were  duly  considered.  The  special 
order  and  details  of  swaged  work  were  then  taken  up,  with  incidental 
'allusions  to  plastic  work,  by  way  of  comparison  or  contrast.  Operations, 
materials,  and  apparatus  peculiar  to  the  latter,  will  form  the  subjects 
of  this  and  succeeding  chapters. 

Plastic  work  includes  all  dental  substitutes  in  which  the  base 
plate  is  brought  into  contact  with  the  teeth  and  the  model  of  parts  to 
be  fitted,  whilst  in  a  fluid,  softened  or  plastic  condition,  then  hard- 
ened, during  continuance  of  this  contact,  either  by  the  application 
or  the  withdrawal  of  heat.  Plasticity,  as  thus  used,  is  the  property  of 
beiug  moulded,  and  has  already  been  spoken  of  as  an  essential  quality 
of  impression  materials.  In  them  it  is  associated  with  other  qualities 
especially  fitting  them  for  their  particular  use ;  so  in  plastic  work,  mere 
plasticity  is  of  no  avail,  if  other  properties  do  not  give  to  the  material 
the  qualities  essential  to  a  base  plate.  It  must  have  strength  and  dura- 
bility, and  must  be  in  harmony  with  the  parts  to  which  it  is  applied. 
This  harmony  implies  that  it  shall  not  act  injuriously  upon  the  mouth, 
or  receive  injury  from  it;  that  it  shall  not,  in  form,  color,  taste,  or  smell, 
be  repulsive  to  patients.  It  ought  not,  if  possible,  to  be  even  objection- 
able ;  but  tastes  are  so  variable,  that  this  contingency  cannot  be  a 
positive  ground  for  exclusion  of  an  otherwise  valuable  material. 


MOULDED   PLATES   OF   PLASTIC   MATERIALS.  817 

As,  in  swaged  work,  there  are  four  metals  of  which  plates  may  be 
formed — gold,  platinum,  aluminum,  and  silver — in  plastic  work, 
there  are  five  varieties  of  plastic  material  of  which  plates  may  be 
moulded :  1,  Porcelain  clay ;  2,  tin  and  its  alloys ;  3,  sulphurated  gum  ; 
4,  celluloid;  5,  aluminum.  The  first  two  have  been  longest  in  use; 
the  third  and  fourth  have  become  the  most  important  in  modern 
dentistry ;  the  fifth  and  latest  has  yet  to  pass  the  ordeal  of  experience. 
The  first  is  moulded  by  tools,  not  in  flasks,  as  are  the  other  four;  it 
also  requires  intense  heat  to  vitrify  or  harden  it.  The  second  is  made 
plastic  by  fusion,  requiring  a  flask,  hot,  to  prevent  cracking  of  teeth, 
and  tight,  to  prevent  escape  of  metal ;  these  plates  harden  by  cold. 
The  third  and  fourth,  less  plastic,  demand  force  in  the  act  of  moulding; 
they  are  hardened  by  heat ;  but  the  temperature  to  which  the  teeth 
are  subjected  is  less  than  in  the  other  three.  The  fifth  is  made  plastic 
by  fusion ;  but,  though  more  plastic  than  the  third,  it  does  not  flow  as 
readily  as  the  second  ;  its  extreme  lightness  and  sluggish  flow  necessi- 
tates peculiar  apparatus  in  moulding. 

Comparing  them  in  respect  of  certain  other  properties — weight,  dura- 
bility, strength,  and  necessary  thickness  of  plate ;  amount  of  change 
in  shape,  from  contraction ;  resistance  to  change  by  the  action  of  the 
buccal  fluids — gum  and  celluloid  are  lightest;  aluminum,  being  thinner, 
is  very  nearly  as  light ;  porcelain,  though  a  light  substance,  requires  such 
bulk,  that  it  is  heavier  than  either ;  tin  and  its  alloys  are  heaviest. 
Gum  plates,  properly  made,  are  strong,  durable,  and  may  be  as  thin 
as  any,  except  aluminum;  aluminum  plates  are  thinnest  and  strongest; 
their  durability  is  still  an  open  question ;  tin  alloys  are  variable,  some 
being  tough  and  strong,  others  stiff  and  brittle,  others  soft  and  flex- 
ible ;  they  have  about  the  same  bulk  as  gum,  and  the  best  are  perhaps 
nearly  or  quite  as  durable.  Porcelain  plates  contract  very  much; 
aluminum  much  less,  but  still  very  considerably ;  tin  alloys  contract 
very  slightly;  gum  has  no  contraction.  Porcelain  most  perfectly 
resists  the  buccal  secretions  and  substances  taken  into  the  mouth  ; 
gum  nearly  or  quite  as  efl^ectually ;  tin  alloys  undergo  some  change ; 
aluminum  is  not  changed  by  sulphur,  as  silver  is,  but  will  probably  be 
found,  in  some  mouths,  to  undergo  slight  change. 

To  give  uniformity  of  nomenclature,  the  four  varieties  of  plastic 
work  will  be  classed  under  four  heads.  1.  Ceramo-plastic,  or  porcelain. 
2.  Metallo-plastic,  including  tin,  cheoplastic  metal,  other  tin  alloys, 
aluminum,  and  gold  alloy.  3.  Vulcauo-plastic,  including  caoutchouc, 
gutta-percha,  and  all  vegetable  substances  that,  by  combination  with 
sulphur,  iodine,  etc.,  have  the  property  of  hardening  by  heat,  under 
the  process  known  as  "  vulcanizing."  4.  Celluloid,  which  is  moulded 
by  heat. 
52 


818  MECHANICS. 

CERAMO-PLASTIC   WORK. 

Porcelain  plates  are  remarkable  for  cleanliness,  and,  in  the  hands 
of  a  skillful  worker  in  the  ceramic  art,  may  have  great  artistic  beauty. 
There  are,  however,  several  considerations  that  must  prevent  their 
extensive  use.  Like  continuous-gum  work,  ceramic  plates  are  adapted 
only  to  full  sets.  They  are  frail,  occasionally  breaking  under  the 
force  of  powerful  mastication  ;  they  will  inevitably  break,  falling  on 
any  very  hard  surface.  It  is  but  just,  however,  to  state  that  the  few 
who  make  porcelain  plates  a  specialty  claim  that  they  are  no  more 
liable  to  accident  than  other  pieces ;  that  the  teeth  of  all,  especially 
continuous-gum,  are  as  apt  to  break  as  this  work  ;  and  that  a  broken 
tooth  or  plate  is  more  easily  and  quickly  mended  in  porcelain-plate 
work  than  in  any  other. 

A  second  objection  is  the  great  shrinkage  of  any  strong  porcelain 
substance.  Efforts  to  correct  in  the  material  itself  this  shrinkage, 
make  it  proportionately  weak.  Correction  by  enlargement  of  the 
model  is  not  only  troublesome,  but  it  is  uncertain  ;  the  same  is  true  of 
the  correction  by  grinding  with  corundum  wheels,  which  is  very 
tedious,  and  cannot  be  exact.  When  base  plates  were  made  of  ivory, 
and  fitted  to  the  mouth  by  carving,  this  imperfection  of  porcelain 
plates  was  not  objected  to,  because  the  former  fitted  no  better,  if  as 
well ;  but  in  contrast  with  the  exact  adaptation  of  other  forms  of 
plastic  work,  and  of  swaged  plates,  it  becomes  very  manifest. 
There  are  many  mouths  in  which  a  porcelain  plate  could  not  be 
retained  at  all ;  there  are  others  which  adapt  themselves  so  readily 
to  moderate  inaccuracies,  that  such  a  plate  is  worn  with  entire 
satisfaction. 

A  third  objection  is  the  necessity  of  constant  practice,  to  keep  up 
that  skill  in  ceramic  art  which  is  essential  to  an  artistic  piece,  and  to 
insure  uniformity  of  result  by  proper  control  of  the  furnace.  This 
difficulty,  however,  can  be  met  in  the  same  way  as  in  continuous-gum 
work.  If  the  dentist  will  make  the  model,  select  and  articulate  the 
teeth,  arrange  them  on  a  temporary  plate  with  wax,  to  give  the  full- 
ness of  gum,  and  a  sample  tooth  to  show  its  color,  then  pack  se- 
curely, and  send  to  any  block  carver  or  porcelain  teeth  manufacturer, 
he  can  have  a  porcelain  plate  made  better,  and  with  more  certainty, 
than  only  an  occasional  practice  will  enable  him  to  do  for  himself.  If 
it  is  desired  that  the  teeth  and  plate  shall  be  carved  at  the  same  time, 
it  will  be  suflScient  to  send  correct  model  and  articulation,  with  direc- 
tions as  to  the  style,  color,  etc.,  of  the  teeth.  We  think,  however,  that 
it  will  be  safer  for  the  dentist  to  select  and  arrange  the  teeth,  as  he 
can  better  judge  what  is  appropriate  than  one  who  does  not  see  the 
patient. 


METALLO-PLASTIC  WORK.  819 

For  details  of  construction,  the  reader  is  referred  to  other  chapters. 
Impression  and  model  are  made  like  any  other  work ;  articulating 
processes  are  the  same  as  for  other  forms  of  plastic  work  ;  grinding 
teeth  is  very  simple,  as  in  continuous-gum  work;  enlargement  of  the 
"  furnace  model  "  and  manipulation  of  the  porcelain  mixture  will  be 
described  in  the  chapter  on  Porcelain. 

The  second  variety  of  Plastic  work  will  be  described  in  the  next 
chapter,  under  the  head  of  Metal lo-plastic  Work.  The  third  and 
fourth  varieties  will  be  considered  under  the  heads  of  Vulcanite 
and  Celluloid  Work. 


CHAPTER  XV. 

METALLO-PLASTIC   WORK. 

THE  use  of  a  fusible  metal  in  the  construction  of  base  plates  is  by 
no  means  new  ;  but  many  of  the  metallic  compounds  suggested,  or 
now  used  for  this  purpose,  are  of  quite  recent  introduction.  Except 
aluminum,  none  of  them  fuse  above  the  melting  point  of  tin,  440°. 
Pure  tin  is  the  oldest  form  of  metallo-plastic  base  plate,  and  was  used 
exclusively  for  the  lower  jaw.  It  is  objectionable  on  account  of  its 
softness  ;  even  in  a  heavy  lower  rim,  it  is  apt  to  bend,  and  for  an  upper 
plate  it  is  wholly  unsuited.  In  its  resistance  to  chemical  change  in  the 
mouth,  it  stands  next  to  gold  and  platinum ;  is  superior  to  silver,  and 
probably  to  aluminum  ;  superior  also,  in  this  respect,  to  any  of  its  own 
alloys.  The  process  of  constructing  a  lower  plate  of  pure  tin  is  the 
same  as  for  any  of  the  tin  alloys. 

Tin  may  be  made  harder  and  more  rigid  by  alloying  with  Gold,  Silver, 
Copper,  Antimony,  Zinc,  Lead,  Bismuth,  or  Cadmium.  Copper  and 
lead  make  it  unfit  for  the  mouth  ;  antimony,  zinc,  and  bismuth  make 
it  brittle,  unless  used  in  very  moderate  proportion.  Silver  gives  it 
hardness,  also  cadmium,  without  imparting  the  objectionable  properties 
named.  Probably  the  best  of  all  alloys  for  tin  is  cadmium.  Closely 
resembling  tin  in  its  physical  properties,  it  hardens  it  without  making 
it  too  brittle,  or  imparting  increased  liability  to  the  action  of  fluids  of 
the  mouth.  The  majority  of  tin  alloys  at  present  recommended  for 
base  plates  contain  cadmium,  with  some  zinc,  antimony  or  bismuth  ; 
they  ought  not  to  contain  copper  or  lead.  In  absence  of  their  for- 
mulas of  composition,  it  is  impossible  to  say  that  they  will  prove  inju- 
rious or  harmless  in  the  mouth,  or  that  they  will  undergo  no  change 


820  MECHANIOS. 

by  time.     Even  if  we  knew  the  formulas,  it  would,  in  some  cases,  be 
impossible  to  speak  positively  on  this  point. 

The  primary  strength  of  any  of  these  alloys  can  be  easily  detected  ; 
with  rather  more  trouble,  its  fusion  point  and  free  flowing  qualities  may 
be  learned.  For  all  else,  the  safest  rule  is  to  use  any  or  all  of  them 
"  under  protest,"  until,  by  personal  observation,  every  one  ascertains 
for  himself  how  far  they  are  free  from  change,  or  keep  their  original 
strength  after  being  worn.  It  may  be  thought  that  such  distrust  of 
the  assertions  of  others  is  unprofessional.  Possibly  it  may  be ;  but 
what  other  course  is  open  to  any  careful  operator,  in  the  face  of  such 
circulars  as  the  one  just  received  by  the  writer,  in  which  a  certain 
"  rubber  preparation  "  is  recommended,  as  enabling  the  dentist  to  com- 
plete a  set  of  teeth  in  "  one  hour  after  taking  the  impression."  The  sad 
truth  is  too  notorious  for  concealment,  that  the  inventors  of  dental 
"improvements"  are  like  the  discoverers  of  quack  medicines — they 
magnify  excellences,  conceal  defects,  substitute  assertion  for  evidence, 
and  claim  a  confidence  in  their  inventions  which  should  only  be  the 
slow  growth  of  experience. 

Experiments  in  tin  alloys,  unlike  those  in  vulcanite  compounds,  are 
easily  made  by  any  well  informed  dentist;  he  can  have  his  favorite  tin 
alloy,  as  he  has  his  pet  solder,  both  the  result  of  his  own  experiment- 
ing. He  can  judge  at  once  of  certain  properties ;  for  others,  he  must 
wait  the  teachings  of  experience.  If  he  prefers  to  use  the  labor  of 
another,  and  buy  an  alloy  which  pleases  him,  but  of  which  he  really 
knows  nothing,  why  should  not  full  judgment  upon  this  also  be 
suspended  until  a  jury  of  his  patients  have  rendered  their  verdict. 

C heoplastic,  Wood's,  Weston's  and  Watt's  Metals. — The  Cheoplastic 
Metal  was  patented  by  Dr.  A.  A.  Blandy,  in  1856,  together  with  certain 
processes  used  in  the  construction  of  dental  plates.  The  manipulations 
since  so  familiar  in  the  working  of  vulcanite,  were  then  as  unknown 
as  vulcanite  itself.  The  peculiar  merits  of  plastic  work  were  at  once 
recognized  by  many  of  the  profession  ;  and  the  Cheoplastic  process 
would  have  passed  into  very  general  use,  with  such  modifications  as 
experience  may  have  dictated,  had  it  not  been  for  the  introduction 
of  Hard  Rubber.  After  some  years'  contest,  the  profession  decided  in 
favor  of  rubber.  Dr.  Blandy's  departure  from  the  States,  in  1862, 
and  the  failure  of  the  supply  of  his  metal,  led  to  a  total  disuse  of  the 
cheoplastic  metal. 

The  abuses  of  vulcanite,  and  the  gross  mismanagement  of  rubber 
patents,  during  their  continuance,  urged  many  advocates  of  plastic 
work  to  revert  to  various  tin  alloys,  which  are,  in  their  principle  of 
composition,  and  in  the  essential  character  of  the  processes  employed, 
identical  with  Dr.  Blandy's  patents.     The  name  chosen  by  him  (signi- 


METALLO-PLASTIC   WORK.  821 

fying  the  making  of  plates  by  pouring  a  metal  made  plastic  by  heat) 
is  equally  applicable  to  all  alloys  of  tin  now  used.  The  alloy  of  the 
cheoplastic  metal  was  silver,  with  some  bismuth,  and  a  trace  of  anti- 
mony. The  exact  proportions  are  not  known,  but  may  be  learned  by 
reference  to  the  patents.  The  alloy  imparted  no  taste  whatever  to  the 
mouth ;  and  its  purity,  so  far  as  its  capability  of  resisting  the  action 
of  the  secretions  of  the  buccal  cavity  is  concerned,  was  said  to  be  equal 
to  eighteen-carat  gold.  Its  color  became  slightly  darker  after  being 
worn  some  weeks,  but  was  immediately  restored  by  placing  it  in  a 
strong  solution  of  caustic  potash. 

The  cheoplastic  metal  was  the  pioneer  of  the  numerous  alloys  of  tin 
(stannum)  which  are  now  claiming  the  attention  of  the  profession. 
We  have  elsewhere  spoken  of  the  necessity  of  testing  all  such  alloys  in 
the  crucible  of  "  practice."  We  shall  mention  those  of  Drs.  B.  Wood, 
H.  Weston,  and  George  Watt.  The  first,  because,  next  to  the  cheo- 
plastic metal,  it  has  been  longest  known  to  the  profession,  particu- 
larly those  alloys  adapted  to  the  filling  of  teeth.  The  last,  because 
they  are  very  strong,  flow  well,  and  retain  their  color  well. 

Of  the  composition  of  Dr.  Weston's  alloy,  we  know  nothing  beyond 
an  assurance  that  it  contains  no  copper,  antimony,  zinc  or  lead.  It 
may  be  better  than  any  of  its  competitors,  closely  resembling  it ;  but, 
in  ignorance  of  the  formulae  of  any  of  them,  we  can  only  say  what, 
perhaps,  if  we  knew  these  formulse,  we  might  still  say — submit  to  the 
test  of  experience  that  which  seems  to  be  the  best.  Dr.  Wood's  alloys 
are  the  result  of  an  elaborate  series  of  very  careful  experiments  made 
some  ten  years  ago.  His  plate  alloys  consist  mainly,  perhaps  alto- 
gether, of  tin  and  cadmium;  they  vary  in  fusibility,  hardness  and 
rigidity,  but  are  nearly,  if  not  all,  more  fusible  than  Weston's  metal. 
Watt's  metal  is  said  to  withstand  the  chemical  action  within  the  mouth 
as  well,  if  not  better,  than  eighteen-carat  gold,  and  to  be  strong,  and  to 
run  sharp.  Moulds  may  be  made  in  almost  any  flask,  but  a  special 
flask,  known  as  Watt's  Moulding  Flask  (Fig.  626),  is  belter  adapted 
to  the  use  of  this  metal  than  the  ordinary  flask.  The  following  instruc- 
tions, in  connection  with  what  remain  to  be  given  for  vulcanite,  will 
be  a  sufficient  guide  in  the  construction  of  plates  made  of  Wood's, 
Weston's,  Watt's,  or  any  other  stannic  alloy. 

Teeth  for  rubber  work  are  best  suited  for  this,  with  the  following 
precautions :  First :  Grind  ofi"  the  thin  upper  edge  of  gum  teeth  or 
sections ;  the  anterior  band  is  useful  in  rubber,  and  does  no  harm  ;  if  of 
metal,  it  is  apt  to  crack  the  block,  and  is  unnecessary,  as  teeth  are 
rather  more  firmly  set  in  metal  than  in  rubber;  hence,  no  metal  should 
overlap  the  upper  edge  of  the  gum.  Secondly:  In  jointing  blocks,  do 
it  as  squarely  as  possibly ;  if  merely  the  edges  of  gum  touch,  the  slight 


822 


MECHANICS. 


contraction  of  the  alloy  may  cause  them  to  scale  or  break.  If,  however, 
from  accident  or  necessity,  this  last  kind  of  joint  occurs,  do  as  in  sol- 
dering blocks  to  gold  plate — place  a  thin  piece  of  paper  in  the  joint, 
before  securing  it  to  the  wax  plate.  Before  drying  the  flasks,  this 
slight  space  caused  by  the  paper  may  be  closed  with  plaster  and  soluble 
glass,  to  prevent  metal  from  running  in  and  making  a  metallic  seam  on 
the  front  of  the  block.  Thirdly :  Be  careful  to  cover  the  pins  with  the 
wax  which  gives  shape  to  the  metal,  so  that  in  finishing  up  the  latter 
they  will  not  be  exposed. 

Fig.  627  represents  Weston's  improved  flask,  which  consists  of  two 
rims  without  top  or  bottom,  to  permit  rapid  escape  of  moisture.  It  is 
much  larger  than  the  ordinary  flasks,  so  as  to  allow  room  for  the  gate 

Fig.  626. 


and  reservoir  posterior  to  the  plate.  It  closes  with  two  small  bolts 
with  nuts,  and  stands  on  feet.  It  is  very  important  to  screw  the  flask 
up  well  before  pouring,  that  the  weight  of  fluid  metal  may  not  sepa- 
rate the  halves  of  the  flask ;  the  slightest  space  will  allow  much  or  all 
the  metal  to  flow  out. 

The  plaster  may  be  mixed  with  soapstone  powder,  pumice  powder, 
or  clean  white  sand.  Asbestos  would  prevent  shrinkage,  but  its  fibres 
would  interfere  with  the  free  flowing  of  the  batter.  The  same  care  in 
heating  the  flask  is  necessary  as  before  stated,  remembering  that  plaster 
confined  in  metal  flasks  takes  longer  to  become  dry.  It  is  not  safe  to 
pour  under  less  than  three  hours'  drying;  and  this  must  never  be  done 
in  direct  contact  with  flame.     Moisture  is  one  of  the  products  of  com- 


METALLO-PLASTIC   WORK. 


823 


bustion  in  all  flame,  and  is  largely  absorbed  by  the  plaster;  hence 
plaster  over  flame  can  never  be  made  perfectly  dry,  unless  contained 
in  some  box,  say  of  sheet  iron,  excluding  this  vapor. 

Directions  for  heating,  pouring,  cooling  off"  and  finishing,  are  as 
follows  : — 

All  necessary  trimming  of  the  plaster  is  done  befoi'e  the  wax  is 
removed,  to   prevent  small  pieces  from  falling  in  the  matrix  by  the 

Fig.  627. 


sides  of  the  teeth.  All  of  the  wax  is  now  removed,  as  the  absorption 
of  any  considerable  portions  left  in  the  matrix  has  a  tendency 
to  roughen  the  surface,  and  thus  to  prevent  the  metal  from  running 
as  smoothly  as  it  would  otherwise  do.  After  removing  the  wax,  each 
half  of  the  matrix  may  be  held  over  the  flame  of  a  tallow  candle,  until 
a  slight  coating  of  lampblack  forms  on  it.  The  two  parts  are  now 
screwed  firmly  together. 


824 


MECHANICS. 


The  flask  may  be  placed  in  a  kitchen  range  or  bake  oven,  and 
exposed  to  a  bread-baking  heat,  say  from  300^  to  400''  Fahrenheit,  for 
from  three  to  five  hours,  or  until  every  particle  of  moisture  is  driven 
from  it ;  then  placed  in  an  upright  position,  the  melted  metal  poured 
quickly  into  the  matrix.  If  there  is  no  ebullition,  and  the  metal  comes 
up  into  the  vents  freely,  the  piece  will  come  from  the  matrix  in  a  perfect 
condition.  If  it  bubbles,  it  may  be  lightly  tapped  several  times  on 
some  hard  surface.  When  perfectly  cold,  the  two  parts  of  the 
matrix  are  separated,  exposing  one  of  the  surfaces  of  the  plate. 

When  the  process  is  properly  conducted  from  the  beginning  up  to 
the  point  of  pouring  the  metal,  the  piece  will  come  from  the  matrix 
perfect  in  all  its  parts.  But  when  the  metal  fails  to  flow  freely  around 
the  teeth,  and  to  cover  perfectly  the  alveolar  border  and  palatine 
arch,  it  is  better  to  replace  the  removed  half  of  the  matrix ;  then, 
turning  the  gate  down,  heat  it  up  to  the  melting-point  of  the  metal ; 

Fig.  628. 


place  again  in  the  sand-bath,  and  pour  a  second  time.  Attempts  are 
sometimes  made  to  patch  the  plate  where  the  defects  are  small ;  but  it 
will  prove  far  more  satisfactory  in  the  end  to  pour  it  entirely  anew. 
The  matrix  should  become  entirely  cold  before  any  attempt  is  made 
to  remove  the  piece  ;  otherwise,  there  will  be  danger  from  the  sudden 
exposure  of  warm  teeth  to  the  air.  The  plaster  mixture  is  easily  cut  ; 
dipping  it  in  water  will  make  it  softer,  and  more  easily  removed. 

If  care  has  been  used  in  shaping  the  wax  plate,  if  the  plaster  has 
been  kept  free  from  air  bubbles,  and  if  the  joints  between  gum  teeth  or 
blocks  have  been  nicely  jointed  and  filled,  on  their  front  edge,  with  the 
plaster  moistened  with  soluble  glass,  the  piece  may  be  finished  with 
little  trouble.  The  gate  and  vents  and  irregular  edges  of  the  plate 
may  be  sawed  off"  or  removed  with  coarse  files ;  fine-cut  files  become 
clogged  with  the  metal.     Scrapers  (Fig.  628)  are  made  for  removing 


METALLO-PLASTIC   WORK. 


825 


the  roughness  of  surface ;  curved  and  rounded  for  the  inner  surface  ; 
flat,  straight-edged,  and  pointed  for  outer  surfaces  or  dental  interstices. 
If  carelessness  in  making  the  wax  plate  renders  it  necessary  to  cut 
away  much  thickness  of  metal,  the  lathe  burrs  used  for  vulcanite  will 
be  found  useful.  In  reducing  the  thickness  of  plates,  frequent  use  of 
calipers  (Figs.  629,  630)  is  necessary  to  avoid  the  accident  of  cutting 

Fig.  629. 


through  the  plate.  This  is  especially  apt  to  happen  in  the  use  of 
lathe  burrs.  Fig.  630  should  have  the  tips  on  one  side  pointed,  as  in 
Fig.  629,  and  they  should  be  occasionally  examined,  to  see  if  both 
sides  come  together  alike.  It  will  make  the  use  of  calipers  more  easy, 
if  the  arras  are  kept  permanently  open  by  an  elastic  band,  closing  by 
pressure  of  the  fingers  at  each  trial  of  the  plate.  Graduated  calipers 
are  useful  also  for  measuring  the  depth  of  articulating   rims,   the 

Fig.   630. 


length  of  teeth,  etc.,  and  are  quite  indispensable.  This  done,  the  sur- 
face is  rubbed  first  with  coarse  and  afterward  with  fine  emery  cloth, 
then  washed  in  soap  and  water  with  a  hard  brush,  afterward  burnished 
and  finished  by  polishing  with  chalk  on  a  brush  wheel ;  coarse  Scotch 
stone  may  be  used  in  place  of  the  emery  cloth.     The  upper  surface  of 


826  MECHANICS. 

the  plate  must  neither  be  scraped  nor  polished,  as  the  accuracy  of  its 
adaptation  to  the  gums  and  palatine  arch  Avould  be  injured  ;  it  should 
simply  be  washed  well  with  a  brush,  using,  perhaps,  a  little  whiting. 
Every  other  part  ought  to  be  finished  in  the  neatest  and  most  perfect 
manner  ;  the  piece  is  put  in  a  strong  solution  of  caustic  potash,  boiled 
for  two  or  three  minutes,  then  washed  in  pure  water,  wiped  dry,  and 
finished  with  chalk  and  the  brush  wheel. 

Under  no  circumstances  should  the  tin  alloy  be  gilded.  The  least 
imperfection  of  the  electrotype  deposit,  or  the  abrasion  of  any  edge  or 
prominence,  or  the  removal  of  the  coating  by  trimming  the  plate  at 
any  point,  presents  to  the  fluids  of  the  mouth  two  metals  having  widely 
different  galvanic  relations ;  electric  action  is  inevitable,  causing  de- 
composition of  the  plate,  annoyance  to  the  patient,  and  often  ulceration 
of  the  gum.  The  tin  alloys  are  quite  harmless  in  the  mouth.  They 
all  slightly  tarnish,  but  the  surface  oxide  seems  to  protect  from  further 
action,  except  where  abraded  by  the  mastication  of  food.  The  brilliant 
polish  of  new  work  cannot  be  kept  so  long  as  on  a  gold  plate,  because 
it  is  much  softer  ;  this,  however,  is  of  secondary  importance,  provided 
the  metal  is  hard  enough  to  resist  wearing  away  under  the  necessary 
operations  of  use  and  of  cleansing. 

In  mounting  a  set  of  teeth  for  the  lower  jaw,  the  gate  through  which 
the  metal  is  poured  into  the  matrix  should  have  two  lateral  branches, 
one  on  each  side,  to  admit  the  metal  more  freely.  The  wax  plate 
should" also  be  thicker,  to  give  suflicient  strength  and  stability  to  the 
base ;  in  other  respects,  the  process  is  the  same  as  that  described  for 
an  upper  set.  For  a  partial  lower  set  of  molars  and  bicuspids  on  each 
side,  the  wax  plate  should  be  extended  behind  the  remaining  front 
teeth ;  and  two  or  three  thicknesses  should  be  applied  here,  giving 
stiffness  sufficient  to  prevent  breaking  or  bending  under  the  pressure 
of  mastication. 

In  making  an  antagonizing  model  for  an  entire  set  of  teeth,  the  wax 
plate  for  the  lower  jaw  is  stiffened  by  the  adjustment  of  a  stout  iron 
wire,  bent  to  the  curvature  of  the  arch,  and  made  fast  to  and  partly 
bedded  in  the  plate.  The  rim  of  wax  is  now  arranged  on  the  ridge, 
and  after  being  properly  trimmed,  it  is  taken  from  the  model.  Upper 
and  lower  plates  are  then  adjusted  in  the  mouth  ;  the  articulation  is 
obtained,  and  the  articulator  (Fig.  631)  made  in  the  manner  described 
for  a  full  set  of  teeth  mounted  on  gold  plate.  Fig.  632  represents  a 
double  set  of  teeth  arranged  in  wax  upon  a  plaster  articulation,  ready 
to  be  placed  upon  their  respective  models  preparatory  to  the  formation 
of  the  remaining  halves  of  the  matrices.  The  cast  base  process  is 
also  applicable  to  partial  sets  of  teeth ;  a  single  tooth,  or  several  teeth 
situated  in  different  parts  of  the  arch,  can  be  replaced,  and  retained  so 


METALLO-PLASTIC   WORK. 


827 


as  to  occasion  no  inconvenience  or  annoyance  to  the  patient.  The 
only  precaution  necessary  to  be  observed  in  their  construction,  in  ad- 
dition to  that  of  accuracy  of  adjustment  and  neatness  of  execution,  is 
to  thicken  the  projections  of  the  wax  plate  between  the  remaining 
natural  teeth  sufficiently  to  give  strength  to  the  metal  at  these  points. 
These  portions,  when  very  narrow,  should  have  twice  the  thickness  of 
the  other  parts  of  the  plate.  Clasps  cannot  be  used,  as  the  metal 
itself  has  no  elasticity,  and  gold  clasps  could  not  be  connected  to  such 
plates.  With  this  exception,  the  forms  of  partial  pieces  for  this  work 
are  the  same  as  for  vulcanite  work,  hereafter  described.  After  having 
adjusted  the  artificial  teeth,  and  made  them  fast  to  the  wax  plate,  the 
teeth  of  the  model  should  be  cut  off  before  making  the  other  half  of 
the  matrix,  as  it  would  be  almost  impossible  to  separate  the  two 
halves  without  breaking  the  teeth  and  other  important  parts. 

But  if  proper  flasks  are  used,  it  is  not  necessary  to  cut  off  the  teeth. 
In  the  same  manner,  as  hereafter  described  for  that  work,  the  model 


Fig.  631. 


Fig.  632. 


may  be  set  in  the  deep  half  of  the  flask  until  the  edges  of  the  teeth  are 
nearly  or  quite  level  with  the  edge  of  the  flask  ;  the  investing  plaster 
supports  the  outside  of  the  teeth,  and  prevents  breakage  on  separating 
the  flask. 

A  piece  from  which  one  or  more  teeth  have  been  broken  can  be 
easily  repaired.  If  any  portion  of  the  tooth  remain  it  is  removed,  and 
the  metal  that  united  it  to  the  base  filed  away  ;  a  new  tooth  is  selected, 
and  ground  until  it  corresponds  with  the  adjoining  teeth ;  it  is  then 
put  in  place,  and  wax  applied  on  the  outside  and  inside  of  the  tooth, 
smoothing  it  with  the  warm  wax  knife  evenly  with  the  plate.  The 
apex  of  a  conical-shaped  roll  of  wax,  about  an  inch  and  a  half  in 
length,  is  united  to  the  wax  on  the  back  part  of  the  tooth;  the  apex 
should  be  little  more  than  an  eighth,  and  the  base  half  an  inch  in 
diameter,  which  latter  should  be  half  an  inch  above  the  edge  of  the 
teeth.  A  small  stem  of  wax  is  united  to  the  wax  on  the  outside  of 
the  tooth,  with  the  free  extremity  half  an  inch  above  its  edge.     The 


828  MECHANICS. 

one-half  of  the  flask  is  now  filled  full  of  the  plaster  mixture,  and  the 
piece  put  immediately  in  it,  with  the  base  downward,  first  filling 
the  irregularities  of  the  plate  with  the  plaster ;  the  top  or  other  half 
of  the  flask  is  then  put  on,  and  a  thin  mixture  of  the  same  composi- 
tion is  poured  on  top,  filling  the  ring  and  covering  the  edges  of  the 
teeth  about  a  quarter  of  an  inch.  When  hard,  the  projecting  stems 
of  wax  are  withdrawn;  the  wax  on  each  side  of  the  tooth,  and  be- 
tween it  and  the  base,  will  be  melted  and  absorbed  during  the  drying 
process.  The  matrix  is  dried  in  a  stove  or  furnace,  being  careful 
not  to  heat  it  up  to  the  point  of  fusion  of  the  plate.  The  alloy  is 
then  melted,  and  poured  into  it  through  the  gate  behind  the  tooth,  and 
if  it  flows,  filling  the  vent  in  front  without  bubbling,  the  piece  will 
come  from  the  matrix  perfectly  restored.  When  cold,  the  plaster 
mixture  is  broken  from  the  teeth,  and  the  metal  around  the  new 
tooth  finished  according  to  the  direction  given  for  full  sets.  In  repair- 
ing pieces,  the  heating  of  the  matrix  and  metal  must  be  done  very 
carefully.  If  the  matrix  is  too  hot,  the  plate  may  fuse ;  if  too  cool 
and  the  melted  metal  too  hot,  porcelain  may  be  cracked.  In  using 
tin  alloys,  in  connection  with  platina  pins,  it  should  be  remembered 
that  the  exposure  of  a  single  rivet  to  the  action  of  the  buccal  fluids 
forms  a  galvanic  battery,  which  will  cause  an  unpleasant  taste,  and 
render  the  piece  liable  to  slow  decomposition ;  hence  all  pins  must  be 
carefully  covered  with  metal,  so  as  not  to  be  exposed  in  the  finishing 
processes. 

We  have  seen  pieces  made  of  Weston's  alloy  which,  after  cutting 
off  the  gate  and  vents,  were  ready  for  the  emery-cloth  and  brush- 
wheels.  This  result  can  be  uniformly  secured  by  care  in  shaping  the 
wax  and  proper  attention  to  temperature  in  pouring.  These  alloys 
have  a  slight  shrinkage,  not  sufficient  to  break  blocks  or  chip  the 
edges,  if  the  directions  above  given  are  observed.  The  slight  shrink- 
age gives  these  plates  an  advantage  over  vulcanite,  in  point  of 
adaptation.  Directions  for  repairs  are  the  same  as  in  other  alloys. 
It  is  also  recommended  to  mend  a  broken  tooth  by  investing  as  for 
gold  soldering ;  then  dry  the  piece,  use  muriate  of  zinc  for  a  flux,  and 
solder  with  blowpipe  or  soldering  iron.  After  melting  one-half  the 
pieces  and  disfiguring  the  half  of  the  remainder,  it  will  probably  be 
concluded  that  the  seemingly  more  tedious  process  is  the  shortest. 
Still,  we  do  not  object  to  trial  of  the  blowpipe  and  soldering  iron ; 
experience  is  the  best  of  all  teachers,  perhaps  because  she  enforces  her 
teachings  by  such  hard  blows. 

The  strength  of  the  Wood  or  Weston  metal  permits  its  use  for  par- 
tial pieces,  and  allows  stays  to  be  formed  on  the  plate ;  but  full  clasps 
cannot  be  made,  because  alloys  of  this  class  are  not  sufficiently  elastic. 


METALLO-PLASTIC    WORK.  829 

The  form  of  such  plates  will  be  discussed  iu  the  next  chapter.  In  pre- 
paring the  above  directions,  we  have  discarded  some  innovations  upon 
other  processes,  as  being  anything  but  improvements ;  such,  for  in- 
stance, as  the  recommendation  to  heat  to  210°,  or, "  so  that  it  can  hardly 
be  held  in  the  hand,"  a  flask  containing  teeth  on  to  which  a  metal 
is  to  be  suddenly  poured  at  a  temperature  of  440°.  This  temperature 
may  be  quite  sufficient,  however,  for  some  of  Dr.  Wood's  alloys.  The 
safest  rule  in  all  cases,  except  for  repairs,  is  to  heat  up  to  the  fusion 
point  of  the  alloy.  As  an  offset  to  this  error,  we  notice  a  good  sugges- 
tion for  removing  small  remnants  of  wax  by  washing  out  with  hot 
water.  It  has  an  advantage  over  the  plan  of  allowing  the  hot  dry 
plaster  to  absorb  the  wax,  in  permitting  examination  of  the  pins  and 
joints,  and  allowing  closure  of  front  joints  with  plaster ;  also,  by  en- 
abling the  mould  to  be  thoroughly  cleansed  just  before  closing,  it  pre- 
vents the  accidental  retention  of  small  particles  of  plaster,  which  may 
interfere  with  the  flow  of  the  metal. 

Aluminum  Work. — In  answer  to  the  question  constantly  asked  by 
students,  whether  aluminum  or  aluminium  is  correct,  we  offer  the 
following  explanation  of  the  spelling  adopted  at  the  head  of  this 
section : — 

This  metal  is,  in  nearly  all  works  on  chemistry,  called  Aluminium, 
making  it  similar  in  termination  to  twenty-three  other  metallic  bases 
discovered  by  modern  science,  and  known  by  Latinized  names  ending 
in  turn.  None  of  these,  however,  have  any  practical  value  in  the  Arts 
as  metals,  except  Cadmium,  Magnesium,  Palladium,  Rhodium,  and 
Iridium.  The  last  three  names  are  taken  from  classical  Latin,  the 
first  two  are  Latinized  from  Cadmeia  and  Magnesia.  These  five  metals, 
therefore,  we  would  leave  with  their  chemical  terminations  unchanged  ; 
the  first  two  for  euphony,  the  last  two  out  of  respect  for  antiquity.  But 
we  prefer  the  termination  um  for  the  metallic  base  of  alumina,  for 
three  reasons :  First,  chemical  nomenclature  does  not  demand  iwn, 
since  Molybdenum,  Platinum,  Arsenicum,  and  all  the  metals  known 
to  the  ancients  end  in  um  except  Mercurium  ;  secondly,  the  same 
change  w^hich  makes  cadmium  and  magnesium  from  cadmeia  and 
magnesia,  makes  platinum  and  aluminum  from  platina  and  alumina ; 
thirdly,  because  this  ending  is  uniform  with  Aurum,  Platinum, 
Argentum,  Cuprum,  Zincum,  and  Stannum,  with  which  useful  group 
of  metals  it  has  physical  properties  in  common,  rather  than  with  the 
larger  group  of  metallic  bases  known  only  in  the  chemical  laboratory. 

Sir  Humphry  Davy  inferred,  from  his  discovery  of  sodium  and 
potassium,  that  alumina  was  the  oxide  of  a  metallic  base.  This  con- 
jectural metal,  named  Aluminium,  was  subsequently  discovered  by 
Wcihler,  but  remained  for  more  than  twenty  years  a  mere  chemical 


830  MECHANICS. 

curiosity,  until,  in  1854,  St.  Clair  Deville  succeeded  in  manufacturing 
it  in  large  ingots  by  the  action  of  sodium  upon  the  chloride  of 
aluminium ;  but  the  cost  of  metallic  sodium  made  this  an  expensive 
process.  He  subsequently  obtained  it  by  the  action  of  chloride  of 
potassium  upon  the  once  rare  mineral  Cryolite — an  alumino-fluoride 
of  sodium,  large  deposits  of  which  have  been  discovered  in  Greenland. 

All  rocks,  except  limestones  and  some  sandstones,  contain  alumina; 
and  it  enters  largely  into  the  composition  of  all  clay  and  slate  rocks  ; 
hence,  next  to  oxygen,  which  constitutes  one-half  of  the  globe,  and 
silicon,  which  forms  one-fourth,  alumina  is  the  most  universally  diffused 
of  all  metallic  oxides,  and  aluminum  is  the  most  abundant  of  all 
metals.  The  vast  beds  of  iron  oi-e  become  insignificant  compared  with 
the  ore  beds  of  aluminum.  As  iron  is  now  the  most  useful  as  well  as 
the  most  abundant  of  all  metals,  it  may  not  be  unreasonable  to  anti- 
cipate the  time  when  the  extent  and  variety  of  uses  to  which  aluminum 
will  one  day  be  applied  shall  be  proportioned  to  the  vastness  of  its  ore 
beds.  The  present  use  of  aluminum,  in  dentistry  and  in  the  arts 
generally,  bears  a  small  proportion  to  its  future  use,  when  its  prop- 
erties shall  become  developed,  the  manner  of  working  it  better  under- 
stood, its  metallurgy  simplified,  and  its  relations  to  other  metals 
ascertained  by  experiment.  Its  valuable  qualities  now  known,  and  its 
history  during  the  sixteen  years  just  passed,  go  far  to  justify  these 
expectations.  We  shall  give  a  brief  summary  of  the  present  state  of 
knowledge  of  aluminum. 

It  is  the  lightest  metal  known  except  magnesium  (excepting  also,  of 
course,  sodium  and  potassium)  ;  its  specific  gravity  is  2.56  for  cast 
metal  and  2.67  for  hammered  metal,  about  the  weight  of  glass  or 
porcelain.  Its  point  of  fusion  is  somewhere  near  1000°  Fahrenheit.  It 
is  malleable,  laminable,  and  ductile  in  a  high  degree ;  has  a  hardness 
equal  to  silver,  and  excels  it  in  point  of  tenacity  ;  it  is  eight  times 
better  than  iron  as  a  conductor  of  electricity,  being  nearly  equal  to 
silver.  Unlike  silver,  it  wholly  resists  the  action  of  sulphur,  also  of 
nitric  acid,  unless  it  is  boiling.  Sulphuric  acid  does  not  affect  it,  nor 
do  the  vegetable  acids,  as  citric,  oxalic  and  tartaric.  Its  proper 
solvents  are  hydrochloric  acid  and  chlorine.  It  is  somewhat  affected 
by  the  caustic  alkalies,  soda  and  potash  ;  also,  perhaps,  by  ammonia 
and  quicklime.  A  solution  of  salt  and  vinegar  is  said  to  affect  it, 
possibly  due  to  a  liberation  of  the  chlorine  in  the  salt. 

Its  record  of  resistance  to  change  by  acid  and  alkali  is  a  very  fair 
one,  and  gives  rise  to  the  conjecture  of  possible  impurity  of  metal,  in 
explanation  of  the  cases  reported  in  which  aluminum  plates  undergo 
change  in  the  mouth.  The  conjecture  is  strengthened  by  the  pecu- 
liarity of  this  change ;  it  occurs  in  spots,  seeming   to  indicate  some 


METALLO-PLASTIC   WORK.  831 

local  impurity  or  alloy,  not  by  a  general  discoloration  of  the  plate, 
such  as  we  see  on  eighteen-carat  gold,  or  silver,  and  on  the  stannic 
alloys.  Hence  we  infer  that  a  perfectly  pure  aluminum  plate  will 
probably  resist  the  secretions  of  the  mouth  ;  also  that  it  is  desirable  to 
avoid  placing  in  the  mouth  alloys  of  aluminum  with  zinc,  tin,  or 
cadmium  ;  and  that  alloys  with  gold,  silver,  or  platina,  will  prove  less 
valuable  than  the  pure  metal.  The  subject  of  aluminum  alloys  in 
connection  with  the  mouth  and  as  solders  is  an  open  field  of  inquiry, 
and  researches  may  some  day  be  crowned  with  the  discovery  of  an 
aluminum  base  plate  equal  in  all  respects  to  gold  plate,  with  the  pecu- 
liar advantage  of  its  remarkable  lightness.  Present  experience  is 
unfavorable  to  its  power  of  resisting  the  buccal  secretions. 

Aluminum  plates  are  swaged,  teeth  backed  and  soldered  by  the 
blowpipe,  just  as  in  gold  work.  The  best  solder  for  this  purpose  is 
probably  Dr.  Starr's,  containing  seven  parts  aluminum  to  one  of  pure 
tin.  Soldering  is  also  done  with  a  copper  soldering  tool  similar  to  that 
used  by  tinners;  sometimes  by  the  combined  action  of  both.  But  the 
results  as  yet  reached,  in  the  experiment  of  soldering  aluminum,  do 
not  justify  us  in  recommending  this  form  of  plate ;  hence  we  shall  not 
give  any  description  of  the  processes  referred  to,  although  esteeming 
them  highly  as  experiments.  The  swaging  of  aluminum  is  done  just 
as  in  case  of  gold  or  platinum,  except  that  frequent  annealing  is  neces- 
sary. The  annealing  must  be  done  with  extreme  care,  since  the  fusion 
point  of  the  metal  is  so  little  above  red  heat  that  the  slightest  excess 
of  heat  will  warp,  blister,  or  melt  the  plate.  The  extreme  lightness 
of  this  metal  permits  the  use  of  a  plate  two  or  three  times  the  thick- 
ness of  gold  plate;  hence  aluminum  plates  may  be  the  very  strongest 
that  can  be  made  in  any  given  case.  The  best  method  yet  proposed 
for  attaching  the  teeth  to  such  a  plate  is  by  vulcanite,  the  details  of 
which  process  will  be  given  in  the  next  chapter.  It  is  a  peculiarity 
of  pure  aluminum  that  vulcanized  rubber  adheres  to  it  with  great 
tenacity.  A  set  of  well-chosen  block  teeth,  skillfully  arranged,  and 
secured  to  an  accurately  fitting  aluminum  plate,  may  safely  be  offered 
to  the  most  fastidious  and  critical  patient.  It  has,  moreover,  the  great 
advantage  that  "  sixty-minute"  dentists  will  not  care  to  imitate  work 
which  takes  "several"  hours  to  do  even  passably  well. 

Another  form  of  aluminum  work,  and  that  Avhich  has  led  to  the 
present  classification  of  this  metal  under  the  head  of  Plastic  work,  was 
the  moulded  or  cast  aluminum  plate.  No  experiments,  however,  seem 
to  us  to  have  been  conducted  with  such  care  as  those  of  the  late  Dr. 
James  B.  Bean,  of  Baltimore,  who  perished  under  an  avalanche,  in  the 
summer  of  1870,  whilst  ascending  Mont  Blanc;  and  his  process  was 
not  only  a  difficult  one  to  pursue,  but  was  very  uncertain  in  its  result ; 


832  MECHANICS. 

hence  the  use  of  aluminum  is  not  at  the  present  time  attempted  except 
in  the  form  of  swaged  plates  to  which  the  teeth  are  connected  by  vul- 
canized rubber,  and  which  is  referred  to  in  the  article  on  Vulcanite. 

In  concluding  this  section,  we  repeat  that  the  use  of  aluminum  in 
dentistry  is  of  recent  origin,  the  properties  of  the  metal  undeveloped, 
and  its  most  appropriate  manipulations  as  yet  undetermined.  Al- 
though experiments  thus  far  indicate  a  want  of  durability,  they  reveal 
properties  which  should  stimulate  to  renewed  effort  in  overcoming 
acknowledged  difficulties.  Taking  lesson  from  the  injury  which  the 
cheapness  and  facility  of  vulcanite  have  inflicted  upon  prosthetic 
dentistry,  we  may  possibly  find  in  aluminum  a  dental  base  possessed 
of  an  unsurpassed  combination  of  excellences ;.  requiring,  however,  for 
their  development  an  amount  of  time,  care  and  skill  that  will  exclude 
it  from  the  practice  of  those  who  are  doing  such  discredit  to  their  voca- 
tion. We  should  regard  this  exclusion  as  one  of  its  highest  recom- 
mendations to  the  notice  of  all  who  seek,  by  the  excellence  of  their 
work,  to  do  honor  to  their  profession. 

Gold  Alloy  Cast  Base. — Dr.  G.  F.  Reese  has  recently  devised  an 
alloy  composed  of  gold,  silver  and  tin,  which  is  manipulated  by  a 
special  method,  as  a  base  for  artificial  dentures,  and  which  has  met 
with  considerable  favor.  A  brief  descrij^tion  of  Dr.  Reese's  method 
is  as  follows :  A  plaster  model  is  first  obtained  from  a  plaster  impres- 
sion of  the  mouth,  and  on  the  model  a  trial  plate  is  made  of  gutta- 
percha, paraffine  and  wax,  or  of  modeling  composition.  Upon  this 
trial  plate  the  teeth  are  arranged  and  tried  in  the  mouth.  If  satis- 
factory, the  waxing  about  the  teeth  is  completed,  and  the  portion  of 
the  trial  plate  covering  the  palatine  surface  is  removed  to  such  a  de- 
gree as  to  nearly  expose  the  pins  of  the  teeth,  the  wax  under  the  gums 
being  allowed  to  remain.  For  the  portion  of  the  trial  plate  removed 
two  thicknesses  of  French  flower  wax  is  substituted,  being  carefully 
adapted  to  the  model. 

Fig.  633  represents  a  case  carried  to  the  stage  described,  the  dotted 
lines  showing  the  edges  of  the  thin  wax  substitute  portion,  and  B,  A, 
and  C,  prominences  of  wax  attached  to  the  posterior  border  and  por- 
tion of  the  plate  covering  the  maxillary  tuberosities,  A  and  C  being 
designed  for  the  escape  of  the  alloy  which  is  poured  in  at  B.  The  case 
is  then  placed  in  a  brass  flask,  which  has  been  oiled,  to  render  its  re- 
moval from  the  investment  easy.  Fig.  634  represents  the  case  in  the 
flask  ready  for  investment.  To  invest  the  case,  each  section  is  placed 
upon  a  plate  of  glass  and  plaster  poured  in  until  it  is  half  filled,  when 
the  model,  which  has  been  saturated  with  water,  is  pressed  into  the 
plaster  batter  until  the  teeth  and  gums  alone  remain  uncovered.  The 
counterpart  of  the  flask  is  then  set  on  and  suflBcient  plaster  poured  in 


METALLO-PLASTIC   WORK. 
Fig.  633. 


833 


until  the  prominences  of  wax  along  the  posterior  border  of  the  trial 
plate  are  slightly  covered.  After  the  plaster  has  set,  the  upper  section 
of  the  flask  is  removed  and  the  surface  of  the  plaster  coated  with 
shellac  varnish.  The  section  of  the  flask  is  then  returned  to  its  place 
and  the  investment  completed  by  filling  it  up  to  the  edges  with  addi- 

FiG.  634. 


53 


834 


MECHANICS. 


tional  plaster.  When  this  has  set  the  flask  is  placed  in  hot  water,  in 
order  to  separate  the  sections  easily.  The  wax  is  then  removed,  and 
also  the  sections  of  the  flask,  by  gently  tapping  them,  and  communica- 
tion made  from  the  outer  surface  with  the  cavities  left  by  the  wax 
prominences  along  the  posterior  border  of  the  plate ;  or,  if  this  is 
impossible,  the  vents  and  gate  may  be  formed  at  the  line  of  division 
between  the  sections,  as  represented  by  the  dotted  lines  in  Figs.  635 

Fig.  S35. 


and  636.  Externally,  the  openings  D  E  and  F,  Fig.  636,  should  be 
enlarged  by  reaming  out  the  plaster,  and  varnished  with  shellac,  to 
receive  the  cylinders,  which  latter  are  made  of  wax,  rolled  thin,  and 
wrapped  around  a  cone-shaped  piece  of  wood.  These  cylinders  are 
about  one  and  a  half  inches  long,  and  about  half  an  inch  in  diameter 
at  the  base,  tapering  to  an  eighth  of  an  inch  at  the  apex. 


METALLO-PLASTIC   WORK. 


835 


The  pouring  cylinder  is  usually  made  somewhat  smaller  at  its  base 
than  the  others,  but  some  two  inches  long.  Wax  covers  are  attached, 
by  a  warm  spatula,  to  the  larger  ends  of  the  cylinders,  so  as  to  make 
them  water  tight.  Fig.  635,  d  e  f,  shows  the  cylinders  thus  prepared 
and  attached.  In  case  the  openings  have  been  made  through  the 
plaster  investment  of  the  lower  section,  as  represented  in  Fig.  635, 
then  the  upper  section,  Fig.  636,  need  not  be  united  to  it  until  the  open- 
ings have  been  formed  upon  the  line  of  division,  when  the  sections 
must  be  joined  before  the  cylinders  can  be  attached.  The  case  is  then 
placed  in  a  larger  flask.  Fig.  637,  and  invested  as  before,  allowing  the 
end  of  the  pouring  cylinder  to  rest  in  the  opening  in  the  posterior  border 
of  the  flask.  In  this  investment  there  is  no  division  of  the  sections 
after  the  parts  of  the  flask  are  filled.     The  case  is  then  dried  in  an 

Fig.  636. 


oven,  all  of  the  wax  being  absorbed  by  the  heated  plaster,  until  all 
moisture  is  expelled.  Several  grades  of  the  alloy  are  used  by  Dr. 
Reese,  which  melt  at  600°  to  700°  F.,  but  a  higher  temperature  is 
necessary  before  the  metal  is  ready  to  pour.  A  temperature  of  900° 
F.,  however,  will  cause  rapid  oxidation,  which,  of  course,  should  be 
avoided.  An  ordinary  ladle  may  be  employed  to  melt  the  alloy, 
which  is  poured,  at  the  proper  temperature,  into  the  opening  of  the 
flask  and  investment.  When  sufficient  time  has  elapsed  for  the  metal 
to  cool,  the  flask  is  opened  and  the  case  presents  the  appearance  repre- 
sented by  Fig.  638,  when  it  is  ready  for  finishing;  the  surplus  alloy 
being  removed  by  a  saw,  and  the  surface  of  the  plate  polished  by 
pumice  on  a  wheel  and  brush. 


836 


MECHANICS. 

Fig.  637. 


Fig.  638. 


VULCA  NO-PLASTIC   WOEK. 


837 


To  repair  this  work,  all  edges  are  scraped  clean,  and  a  space  cut 
between  them  of  about  one-eighth  of  an  inch,  which  is  filled  with  wax 
when  the  set  is  adjusted  on  the  model.  At  each  end  of  the  space  two 
cones  of  wax,  each  about  one-eighth  of  an  inch  in  diameter,  are 
attached,  standing  perpendicularly  to  the  palatal  surface,  and  the 
whole  invested  with  plaster  to  the  depth  of  an  inch.  The  two  sections 
thus  made  are  then  separated,  and  the  wax  is  washed  out  by 
boiling  in  hot  water.  The  external  ends  of  the  spaces  left  by  the  wax 
cones  are  then  countersunk  and  a  larger  wax  cone  is  inserted  into 
each  opening,  the  one  to  form  a  pouring  gate,  and  the  other  to  act  as 
a  vent  for  surplus  metal,  this  last  being  entirely  covered  by  the  plaster 
of  the  investment.  The  entire  piece  is  then  invested  in  a  repair  flask, 
and  the  plaster  thoroughly  dried  and  heated  up  before  the  alloy  is 
poured. 

Fig.  639  represents  a  dental  mould  designed  by  Dr.  Hayford,  for  use 

Fig.  639. 


in  manipulating  Weston's,  Watt's  and  Hayford's  alloys,  and  by  which 
it  is  claimed  all  imperfections  caused  by  air  bubbles  or  failure  of  the 
material  to  cast  sharply  are  overcome.  The  metal  is  introduced  with 
the  flask  partly  open,  and  just  before  crystallization  commences  pres- 
sure is  applied  by  means  of  the  lever,  which  closes  the  flask  and  forces 
the  material  into  every  portion  of  the  mould,  producing  a  sharp,  perfect 
casting. 

VULCANO-PLASTIC   WORK. 

Under  this  name  are  included  all  vegetable  materials  which  have 
been,  or  may  hereafter  be,  incorporated  with  sulphur,  iodine,  or  other 
substances,  for  the  development  of  those  peculiar  properties  so  well 
known  in  hard  ruber.  Inspissated  linseed  oil,  amber,  and  gum  copal, 
etc.,  have  thus  been  experimented  with,  but  with  results  thus  far  very 
unsatisfactory.  They  are  here  mentioned,  because  it  is  by  no  means 
improbable  that  among  the  vegetable  oils,  resins  or  gums,  now  known 
or  to  be  discovered,  there  will  be  found  one  which  shall  excel  any  yet 


838  MECHANICS. 

known,  in  those  remarkable  qualities  imparted  by  sulphur  to  the 
resinous  gums,  gutta-percha  and  caoutchouc.  These  differ  from  some 
other  resins,  in  an  opacity  which  follows  them  through  their  combina- 
tions with  sulphur,  making  it  impossible  to  obtain  even  a  tolerable 
imitation  of  mucous  membrane.  Possibly  some,  as  yet  unknown,  vul- 
canizable  transparent  resin  may  be  found,  carrying  into  its  combina- 
tions enough  of  translucency  to  give  that  peculiar,  life-like  animation 
which  now  characterizes  porcelain-gum  colors  alone.  The  history  of 
coautchouc  teaches  us  that  it  is  not  impossible  we  may  be  in  daily  use 
of  some  such  gum  or  resin.  The  only  compounds  of  gum  (more  strictly, 
resin)  and  sulphur  that  have  been  tried  to  any  extent  are  corallite  and 
vulcanite — the  trade  names  of  sulphurated  gutta-percha  and  sulphur- 
ated caoutchouc ;  also  spoken  of  as  sulphide  of  caoutchouc,  because  the 
new  properties  developed  by  the  union  are  such  as  make  it  appear  to 
be  a  true  chemical  compound,  and  not,  like  the  vermilion,  etc.,  often 
incorporated  with  it,  a  mechanical  mixture. 

Corallite. — Gutta-percha  is  the  resinous  exudation  of  a  forest  tree, 
the  Isonandra  Gutta,  found  extensively  in  Sumatra,  Borneo,  and  the 
Malayan  Peninsula.  It  was  first  brought  to  the  notice  of  Europeans 
by  Dr.  Montgomerie,  of  Bengal,  in  1842,  and  in  a  few  years  attracted 
much  attention,  for  those  valuable  properties  which  have  since  made 
it  so  indispensable  to  the  dentist.  Twelve  years  ago  experiments  were 
made  with  it  in  combination  with  sulphur.  Combined  with  half  its 
weight  of  sulphur,  and  the  compound  then  mixed  with  half  its  weight 
of  vermilion,  it  formed  a  substance  known  as  "  Corallite,"  which  hard- 
ened under  the  same  conditions  as  vulcanite,  and  of  which  it  promised 
to  become  a  formidable  rival. 

Unfortunately,  one  property  of  crude  gutta-percha  followed  it  into 
this  combination — its  tendency  to  become  brittle.  It  is  well  known 
that  sheets  of  this  substance,  whether  the  pure  crude  gum  or  that  pre- 
pared for  dental  use  by  large  admixture  of  foreign  matter,  will  become 
in  time  so  brittle  as  to  break  almost  at  a  touch.  The  vulcanized  gutta- 
percha has  the  same  property  in  less  marked  degree,  but  quite  enough 
so  to  be  fatal  to  its  pretensions  as  a  rival  of  vulcanite.  Hence  coral- 
lite is  no  longer  avowedly  used,  and  even  its  name  is  almost  forgotten. 
So  persistent  is  this  injurious  property  that  it  will  affect  any  rubber 
compounds  with  which  it  may  be  mixed.  Any  suspicion  of  the  pres- 
ence of  gutta-percha  should  condemn  sulphurated  caoutchouc  for  den- 
tal use ;  this  last-named  gum,  however,  may  be  brittle  and  worthless, 
from  admixture  of  other  substances  besides  gutta-percha,  as  will  be 
hereafter  stated. 


VULCANO-PLASTIC   WORK.  839 

VULCANITE. 

Caoutchouc,  formerly  known  as  elastic  resin,  and  still  more  univer- 
sally known  as  India-rubber,  was  discovered  by  certain  French  Acade- 
micians, in  Cayenne,  in  the  year  1735.  For  many  years  its  only 
known  value  was  as  an  eraser  of  lead-pencil  marks.  Dr.  Priestley, 
the  distinguished  discoverer  of  oxygen,  in  the  preface  to  his  work 
on  Perspective,  published  in  1770,  speaks  of  it  as  being  excellently 
adapted  to  the  purpose  of  wiping  from  paper  the  marks  of  a  black- 
lead  pencil.  It  was  still  many  years  after  this  that  it  was  confined 
to  this  use,  and  to  the  making  of  rubber  shoes  and  bottles  by  South 
American  and  East  Indian  natives,  who  formed  them  on  clay  moulds, 
from  the  fresh  exudation  of  the  Siphonia  caliuca,  Jatropa  elastica,  or 
Ficus  elastica.  Upon  discovery  of  a  solvent,  its  uses  were  extended 
by  bringing  to  bear  the  skilled  labor  of  civilization ;  but  the  fact  of 
its  becoming  hard  and  rigid  (yet  not  brittle)  at  48°  greatly  limited 
its  value.  The  principal  solvents  of  caoutchouc  are  spirits  of  turpen- 
tine, bisulphide  of  carbon,  benzol,  ether,  chloroform,  naphtha,  and  the 
essential  oils. 

Mr.  Charles  Goodyear's  discovery  of  the  remarkable  effects  of  sul- 
phur in  combination  with  caoutchouc  has,  since  1840,  extended  the 
application  of  this  gum  to  an  almost  infinite  variety  of  uses.  In  cer- 
tain proportions  and  at  certain  temperatures,  the  sulphur  does  not 
much  impair  the  remarkably  elastic  and  flexible  property  of  the  native 
gum,  but  preserves  it  at  low  temperatures.  Subsequent  experiments 
led  to  the  discovery  of  hard  rubber,  which  at  first  was  made  into 
combs,  buttons,  etc.  It  was  thus  used  for  a  number  of  years  before 
its  application  to  dental  purposes.  This  was  first  attempted  as  early  as 
1853.  Mr.  Bevan,  a  former  employee  of  the  Goodyear  Company,  Dr. 
Putnam,  of  JS"ew  York,  and  Dr.  Mallett,  of  New  Haven,  were  the  first 
persons  known  to  the  writer  as  engaged  in  these  experiments ;  possibly 
others  were  at  the  same  time  thus  occupied.  But  owing  to  the  exceed- 
ingly cumbrous  vulcanizing  apparatus  (Dr.  Putnam's  weighing  twelve 
hundred  pounds),  and  the  absence  of  that  knowledge  of  the  material 
and  those  appliances  for  its  manipulation  which  experience  alone  could 
give,  it  made  very  slow  progress  for  the  first  few  years.  It  has  been 
estimated  that,  in  1858,  not  more  than  three  hundred  dentists  made 
any  use  of  it ;  in  1863  it  was  conjectured  by  Dr.  Franklin  (then  den- 
tal agent  for  the  American  Hard  Rubber  Company)  that  nearly,  if  not 
quite,  three  thousand  employed  it  in  their  practice.  At  the  present 
time,  the  patents  restricting  its  use  having  expired,  it  is  universally 
employed. 

Hard  rubber  possesses,  when  prepared  in  greatest  perfection,  many 
qualities  which  fit  it  for  use  as  a  base  plate.     It  is  impervious  to  the 


840  MECHANICS. 

buccal  secretions  and  unchanged  by  them  ;  it  has  very  considerable 
strength,  great  lightness,  and,  when  properly  vulcanized,  a  high  degree 
of  elasticity.  For  some  purposes  in  prosthetic  dentistry  it  has  no  equal, 
and  for  some  few  it  is  indispensable ;  but  the  merit  of  superior  adapta- 
tion is  shared  by  other  plastic  substances,  and  for  many  cases  we  have 
shown  that  the  fit  of  an  old-fashioned  gold  plate  is  much  to  be  pre- 
ferred. The  annoyance  of  numberless  patents  and  the  cheapness  of 
the  material  are  two  serious  objections  to  its  extensive  use  by  those 
who  regard  dentistry  as  a  profession  rather  than  as  a  trade.  These 
points  are  elsewhere  considered. 

Dental  vulcanite  is  usually  incorporated  with  vermilion,  to  give  it  a 
color  more  generally  acceptable  than  the  dark  brown  of  the  simple 
sulphurated  gum.  But  rubber,  sulphur  and  vermilion  are  all  opaque 
substances,  and  can  never  themselves,  or  by  combination  with  other 
materials,  be  made  to  assume  any  resemblance  to  the  natural  gum, 
which  porcelain  alone  has,  thus  far,  been  able  to  imitate.  The  incor- 
poration of  such  substances  for  this  purpose  has  no  other  effect  than 
seriously  to  impair  the  strength  of  the  material.  Experiments  in  vul- 
canite are  much  more  troublesome  than  those  with  stannic  alloys,  and 
probably  few  will  take  the  trouble  of  making  them.  A  common 
formula  for  the  red  vulcanite  is  caoutchouc,  48  parts ;  sulphur,  24 
parts ;  vermilion,  36  parts.  The  formula  for  a  dark  brown  vulcanite 
is  caoutchouc,  48  parts ;  sulphur,  24  parts ;  this  gives  the  strongest 
rubber.  The  formula  for  a  jet  black  vulcanite  is  caoutchouc,  48  parts ; 
sulphur,  24  parts  ;  ivory,  or  drop  black,  48  parts.  All  colored  rubbers 
are  weakened  by  the  addition  of  foreign  matter,  as  English  pink  vul- 
canite, which  contains  48  per  cent,  of  white  clay.  White  oxide  of  zinc 
in  the  proportion  of  47  per  cent.,  will  give  to  vulcanite  mixed  with 
sulphur  and  vermilion,  a  deep  pink  color.  The  pink  rubbers  are  so 
much  weakened  by  the  admixture  of  foreign  matter,  that  care  must 
be  taken  when  they  are  used  to  produce  a  more  natural  color  of  the 
gum  portion  of  a  denture,  to  prevent  the  pins  of  the  artificial  teeth 
from  being  covered  by  such  rubber.  From  an  extended  series  of 
very  careful  experiments,  by  Prof.  Wildman,  we  condense  the  fol- 
lowing statements : — 

Caoutchouc,  two  parts,  sulphur,  one  part,  form  a  dark-brown  rub- 
ber, which  is  the  strongest  of  the  vulcanites.  Of  all  additions  for 
modification  of  color,  purest  vermilion  is  best ;  it  withstands  heat,  re- 
sists the  action  of  sulphur,  and  has  an  intensity  of  color  that  soonest 
overcomes  the  darkness  of  the  rubber.  Being  a  sulphuret,  it  appears 
to  have  much  less  effect  in  weakening  the  texture  of  the  sulphide  of 
caoutchouc  than  an  equal  quantity  of  any  other  substance  ;  yet  it  does 
diminish  its  strength  in  proportion  to  its  use.     English  deep  red  and 


VULCANO-PLASTIC   WORK.  841 

American  Hard  Rubber  Company's  red  contain,  by  weight,  two  parts 
sulphide  of  caoutchouc  and  one  part  of  vermilion.  There  are  no  better 
varieties  of  red  vulcanite  than  these,  so  long  as  they  are  honestly  pre- 
pared. To  the  red  and  brown  rubbers  white  oxide  of  zinc  or  white 
clay  are  added,  in  proportions  varying  from  .20  to  .57  per  cent.,  to 
produce  grayish-white  or  pink  rubber.  Of  these  the  best  is  Ash  & 
Sons'  pink  rubber  (S.  P.),  containing  gum  sulphur  and  vermilion,  in 
same  proportion  as  English  deep  red,  with  one-fourth  this  weight  of 
white  oxide  of  zinc  added,  to  tone  the  deep  color.  Black  rubber  is 
made  by  adding  to  six  parts  of  the  brown  sulphide  from  two  to  four 
parts  of  ivory  black.  For  the  details  of  these  experiments,  and  much 
other  valuable  information,  the  reader  is  referred  to  Prof.  Wildman's 
monograph, "  Instructions  in  Vulcanite,"  which  should  be  in  possession 
of  all  who  work  in  this  material. 

In  the  selection  of  rubbers  we  unhesitatingly  decide  in  favor  of  the 
brown  vulcanite,  not  from  any  absurd  idea  of  the  injurious  action  of 
vermilion,  which  we  shall  presently  show  to  be  perfectly  harmless,  but 
because  of  its  superior  lightness  and  strength.  We  are  not  justified  in 
sacrificing  these  valuable  qualities  for  the  sake  of  colors,  which  not 
only  have  no  greater  aesthetic  harmony  with  the  mouth,  but  which,  by 
the  brilliancy  of  their  color,  attract  attention  to  this  defect.  We  use 
white  platinum  and  aluminum  and  yellow  gold  ;  ivory,  in  old  times, 
soon  darkened,  and  a  tobacco  chewer  will  blacken  any  vulcanite  plate. 
Why  not,  then,  use  a  brown  base  plate  from  the  beginning?  If  the 
vermilion  rubber  is  used,  let  it,  by  all  means,  have  its  natural  rich 
mahogany  "color,  and  not  the  glaring  brilliancy  with  which  students 
delight  to  invest  their  specimens.  This  does  very  well  in  show  cases, 
and  is  eminently  adapted  to  those  captivating  exhibitions  of  high  art, 
where  a  lovely  wax  face  opens  and  closes,  revealing  alternately  an 
aching  void  and  acheless  grinders  ;  but  in  the  mouth  such  bright 
colors  are  monstrous  violations  of  good  taste. 

Vermilion,  combined  with  rubber,  cannot  have  any  deleterious 
eflfect.  In  no  case  coming  under  our  observation,  have  we  seen  a 
single  symptom  of  local  or  constitutional  action  peculiar  to  vulcanite, 
except  a  sensation  of  heat ;  this  we  take  to  be  an  electric  action,  due  to 
the  fact  that  rubber,  like  sealing-wax,  is  a  powerful  negative  electric. 
It  is  common  to  brown,  red,  pink  and  white  rubbers,  and  there  is  no 
remedy  for  it.  It  is  not  a  constant  symptom  ;  some  patients  never  feel 
it,  some  often,  some  occasionally — dependent,  perhaps,  upon  the  state 
of  the  electric  element  entering  into  the  composition  of  vital  force. 

Pure  sulphuret  of  mercury  is  reckoned  by  Orfila  as  medicinally 
inert.  Fumigation,  by  vaporizing  the  mercury,  gives  it  a  medicinal 
activity ;  but  this  requires  a  temperature  of  600°  Fahrenheit.     There- 


842  MECHANICS. 

fore,  for  the  development  of  constitutional  symptoms,  we  must  have  the 
presence  of  arsenic  or  of  red  lead,  as  impurities  of  the  sulphuret,  or  the 
existence  of  free  mercury. 

First,  as  to  the  impurities  of  arsenic  or  red  lead ;  they  are  not  found  in 
pure  vermilion.  But  even  if  present,  such  poisonous  impurity  would 
be  rendered  harmless,  because  completely  invested  by  an  insoluble 
coating  of  India-rubber.  A  piece  of  vulcanite  is  impervious  to  the 
fluids  of  the  mouth ;  hence  no  part  of  its  substance  can  be  dissolved, 
and  thus  taken  into  the  stomach.  Any  supposed  medicinal  action 
must,  therefore,  come  from  such  minute  particles  as  may  possibly  be 
worn  off  the  lingual  surface  near  the  teeth,  where  bread  crusts  or 
other  hard  particles  of  food  impinge.  White,  gray  and  pink  rubbers 
have  so  large  a  proportion  of  foreign  matter  that  they  are  easily 
abraded ;  but  in  the  pure  red  rubbers  we  have  thus  an  almost  infini- 
tesimally  small  quantity  of  vulcanite  taken  into  the  stomach,  one- 
third  of  which  is  inert  vermilion,  adulterated  (we  will  suppose)  with 
three  per  cent,  of  arsenic,  and  this  coated  with  a  layer  of  rubber, 
which,  as  previously  stated,  is  insoluble  in  water,  alcohol,  alkalies,  or 
weak  acids.  This  very  minute  trace  of  arsenic,  even  if  divested  of  its 
envelop  of  rubber,  would  have  a  purely  homoeopathic  (and,  by  conse- 
quence, not  poisonous)  action ;  while,  if  encased  in  rubber,  which  per- 
vades every  part  of  the  material,  it  is  absolutely  inert.  The  same  may 
be  said  of  the  less  poisonous  adulteration,  red  lead. 

Secondly,  as  to  the  mercury :  the  researches  of  Prof  Johnston,  with 
the  microscope,  and  Prof.  Mayer,  by  chemical  analysis,  have  failed  to 
discover  the  slightest  trace  in  samples  of  the  rubber  used  by  us  for 
several  years.  Prof.  Wildman  found  sulphur  sublimed  during  vulcan- 
ization, but  not  the  smallest  trace  of  mercury.  We  have  failed  by 
any  mechanical  force  to  press  out  any  globules,  nor  have  we  ever,  in 
any  manipulations,  seen  the  slightest  particle  of  this  metal,  or  been 
able  with  the  microscope  to  detect  it  upon  the  surface  of  any  finished 
jDiece.  This  question  of  the  presence  of  free  mercury  in  the  vulcanized 
material  may  perhaps  require  a  more  extended  series  of  experiments. 
It  is  the  only  agent  that  can  possibly  exert  any  deleterious  action 
upon  the  system.  That  its  presence  is  rare  is  proven  ;  that  it  is  never 
found  can  be  confidently  asserted  or  denied,  only  after  the  extended 
observations  recommended,  the  observers,  however,  being  careful  not 
to  confound  the  minute  crystals  of  sulphur  with  globules  of  mercury, 
as  some  have  done. 

Impressions  for  vulcanite  work  may  be  taken  in  plaster,  wax,  gutta- 
percha, or  modeling  composition.  The  minute  accuracy  of  plaster  is  not 
so  essential  in  swaged  work,  since  the  very  fine  lines  of  the  model  are 
partly  lost  in  the  die,  and  could  not  be  impressed  on  the  plate ;  but  in  the 


VULCANO-PLASTIC   WORK.  843 

vulcanite  the  faintest  scratch  is  faithfully  copied.  The  finest  plaster 
must  be  used,  and  stirred  until  all  air  bubbles  are  removed.  Although 
fine  plaster  will  give  the  minutest  lines,  yet  many  prefer,  for  all  labora- 
tory use,  a  moderately  coarse  plaster,  which  becomes  hard  and  strong 
when  it  sets  ;  and  recommend,  in  all  cases  admissible,  plaster  to  be  mixed 
as  thick  as  it  will  work  well,  as  thin  mixed  plaster  expands  more  than 
the  thick  mixed.  The  fracture  of  the  teeth  of  a  plaster  model  may  be 
prevented  by  inserting  small  pieces  of  wire  or  brass  pins  in  the  impres- 
sions of  such  teeth  before  pouring  the  plaster.  The  absolute  necessity 
of  plaster  impressions,  in  most  partial  cases  where  vulcanite  is  used, 
led  Prof  Austen  to  devise  the  method,  elsewhere  described,  of  taking 
impressions  with  gutta-percha  cups.  The  advantage  of  a  partial 
plaster  impression  thus  obtained  are :  first,  the  exact  shape  of  the  out- 
side of  the  teeth  adjoining  the  space  to  be  filled  permits  correct  adjust- 
ment upon  the  model ;  secondly,  the  accurate  shape  of  the  inside  of 
the  molars  and  bicuspids,  at  the  point  where  wax  impressions  drag, 
allows  the  stays  or  half-clasps  to  be  closely  fitted  to  the  teeth. 
But  it  must  be  borne  in  mind,  that  partial  impressions  in  plaster 
and  partial  pieces  in  vulcanite  demand,  for  their  success,  the  utmost 
care  and  nicety  of  manipulation,  a  care  which  the  result  will  fully 
reward.  The  absolute  non-contraction  of  rubber  may  make  wax  or 
gutta-percha  a  better  impression  material  for  full  sets  than  plaster ;  in 
fact,  we  recommend  plaster  less  often  for  full  vulcanite  plates,  than  for 
base  plates  of  any  other  material ;  while  in  partial  cases,  for  reasons 
just  given,  we  prefer  its  almost  exclusive  use. 

Vulcanite  models  require  no  particular  shaping,  except  the  extension 
of  the  back  part  an  inch  or  more,  so  that  the  model  itself  may  serve 
as  one-half  of  the  articulator.  This  not  only  saves  time  and  plaster, 
but  gives  more  accurate  results,  since  there  is  no  transfer  of  the  teeth 
and  wax  plate  to  a  new  model.  When  the  teeth  are  set  in  the  wax 
plate,  the  model  is  then  separated,  with  a  saw,  from  the  back  part,  and 
placed  in  the  flask.  In  double  sets  the  back  part  of  one  model  is 
smoothed,  and  the  T-shaped  groove  cut  and  soaped,  or  covered  with 
thin  foil ;  the  extension  of  the  other  model  is  left  rough,  and  when  the 
articulating  plates  are  made,  the  models  are  set  into  their  respective 
plates  and  the  space  at  the  back  part  filled  with  plaster.  Partial 
models,  containing  a  number  of  teeth,  require  no  other  antagonizer 
than  a  model  made  from  a  simple  impression  in  wax  of  the  lower  teeth, 
which  will  fit  the  irregularities  of  the  teeth  of  the  upper  model. 
Models  for  vulcanite  may  be  coated  with  very  dilute  soluble  glass 
(liquid  silex),  collodion,  or  tin  foil.  The  late  Prof.  Austen,  in  1858, 
sent  his  earliest  experiments  in  rubber  to  Dr.  Putnam,  of  New  York, 
to  be  vulcanized.     The  doctor  wrote  to  know  "  what  the  varnish  was 


844  MECHANICS. 

which  prevented  the  rubber  from  sticking."  It  was  this  soluble  glass, 
used  originally  for  the  purpose  of  hardening  the  surface,  to  prevent 
injury  from  subsequent  manipulations. 

Antagonizing  plates  are  made  by  moulding  a  piece  of  gutta-percha 
over  the  model,  kept  very  wet,  to  prevent  adhesions.  The  central  part 
should  be  not  less  than  one-eighth  of  an  inch  thick,  to  give  stiffness  to 
the  plate  ;  the  rim  on  the  edge  should  be  the  exact  length  of  the  teeth 
required,  and  trimmed  very  carefully  on  the  outside,  to  give  the  proper 
fullness.  The  gutta-percha  should  be  first  worked  into  a  ball,  using 
from  one  to  two  sheets,  according  to  the  size  of  the  mouth  ;  then,  press- 
ing from  the  centre  outward,  the  articulating  rim  is  formed  at  the  same 
time  that  the  material  is  turned  over  the  ridge.  It  is  quickly  done, 
will  not  injure  the  most  delicate  ridge,  and  gives  a  plate  as  unyielding 
as  any  gold  plate.  In  a  lower  set,  the  rim  may  be  stiffened  with  a  piece 
of  heavy  iron  or  copper  wire.  In  a  full,  or  nearly  full,  upper  set,  the 
impress  of  the  lower  teeth  is  to  be  received  in  a  thin  rim  of  wax  set  on 
the  gutta-percha.  In  a  double  set,  the  rims  are  trimmed  till  they  touch 
uniformly,  and  then  their  relation  marked  by  decided  indentations 
across  the  line  of  contact.  It  is  quite  possible,  with  these  gutta-percha 
plates,  to  take  the  articulation  in  every  case  with  such  absolute  accu- 
racy that  no  trial  of  the  teeth  is  necessary,  nor  any  grinding  of  the 
teeth  upon  inserting  them  in  the  mouth.  Metallic  articulating  plates, 
swaged  for  the  case,  are  much  more  troublesome,  and  are  no  better. 
The  usual  method  of  making  them  of  sheet  gutta-percha,  wax,  or  tin- 
f  )il  can  never  give  one  that  full  confidence  in  his  articulation  which 
enables  him  habitually  to  dispense  with  the  trial  of  the  piece  after 
grinding.  As  vulcanite  articulations  are  often  taken,  it  would  be  as 
well  simply  to  look  at  the  mouth  and  guess  at  them. 

The  modeling  composition  is  an  excellent  material  for  a  base  plate 
in  securing  the  articulation.  After  being  softened  and  adapted  to  the 
cast,  a  roll  of  softened  wax  is  placed  upon  the  base  plate,  over  the 
alveolar  ridge,  and  shaped  to  the  form  of  the  arch.  After  being  tried 
in  the  mouth,  and  added  to  or  trimmed  off,  if  too  short  or  too  long,  the 
patient  is  directed  to  bite  into  the  wax.  To  prevent  securing  too  long 
or  too  short  a  bite,  one  or  more  small  blocks  of  soft  pine  wood,  about 
half  an  inch  square  and  thicker  than  the  required  bite,  may  be  attached 
to  the  base  plate  witb  melted  wax,  and  trimmed  off  until  the  necessary 
length  is  obtained.  The  wax  rim  is  then  applied  over  the  block  and 
the  proper  articulation  secured. 

Preparatory  to  the  selection  and  grinding  of  teeth  or  blocks,  the 
thick  articulating  plates  must  be  removed,  and  the  model  covered  with 
thin  druggist's  foil,  and  the  space  inside  the  ridge  filled  with  a  mass 
of  soft  wax,  pressed  out  until  it  meets  the  probable  inside  line  of  the 


VULCANO-PLASTIC   WORK. 


8-15 


teeth  to  be  fitted ;  this  affords  a  much  firmer  support  to  the  teeth 
during  grinding  than  the  usual  practice  of  using  the  thin  wax  or 
gutta-percha  matrix  plate.  The  top  and  outside  of  the  ridge  are  left 
covered  ^vith  foil  alone.  When  blocks  like  Fig.  641  are  to  be  ground, 
passing  over  front  of  ridge  and  surmounted  with  a  rubber  band,  it  is 
essential  that  the  block  shall  not  quite  touch  the  model  at  any  point ; 
this  contact  is  prevented  by  placing  between  the  foil  plate  and  the 
model  a  strip  of  foil,  having  four,  six,  or  eight  thicknesses,  as  may  be 
desired.  But  when  blocks  such  as  Figs.  642  and  643,  or  teeth,  like  Fig. 
640,  are  ground,  resting  directly  upon  the  gum,  with  no  rubber  above 
or  under  the  upper  part  of  the  gumj  the  thin  foil  is  retained  only 
during  the  process  of  grinding,  so  as  to  receive  the  paint  used  in  accu- 
rate fitting  of  blocks;  the  foil  is  then  removed  and  the  plaster  scraped, 
so  as  to  slightly  bed  the  front  blocks  or  teeth  in  the  natural  gums. 
As  the  teeth  are  ground,  they  should  be  attached  to  the  wax  mass  with 
softened  or  melted  wax. 


Fig.  641. 


In  grinding,  the  greatest  care  must  be  taken  to  make  close  joints ; 
but  the  fitting  of  the  base  requires  none  of  the  accuracy  demanded  in 
fitting  gold  plates,  except  when  the  tooth  is  to  be  set  directly  upon  the 
gum.  It  is,  however,  a  mistake  to  suppose  that  a  space  of  half  an 
inch  can,  with  perfect  impunity,  be  left  between  the  teeth  and  plate; 
for  vulcanite  has  a  slight  shrinkage  on  cooling.  Unlike  the  shrinkage 
of  metal,  which  is  irresistible,  that  of  vulcanite  is  controlled  by  the 
matrix,  so  that  it  results  in  no  change  in  the  shape  of  the  plate.  This 
is  proved  by  the  closeness  with  which  it  is  seen  to  adhere  to  the  model 
on  opening  the  matrix.  But  it  takes  place  in  the  direction  of  the 
thickness  of  the  plate.  If,  therefore,  a  large  bulk  of  material  is  inter- 
posed between  the  teeth  and  ridge,  it  will  shrink  perceptibly  either 
from  the  ridge  or  from  the  teeth  ;  in  the  first  case  impairing  the  fit  of 
the  piece,  in  the  latter  case  loosening  the  hold  of  the  rubber  upon  the 
tooth.  Thick  masses  of  vulcanite  are  also  apt  to  be  porous  or  honey- 
combed, owing  to  the  evolution  of  sulphur.      That  sulphur  is  evolved 


846  MECHANICS. 

in  all  cases  is  evident,  from  the  staining  of  the  plaster,  blackening 
of  the  flasks  and  inside  of  the  vulcanizer,  and  from  the  peculiar 
smell  whenever  there  is  escape  of  steam.  We  sometimes  find  it  makes 
the  rubber  porous,  especially  in  lower  cases,  in  spite  of  every  precau- 
tion taken  to  prevent  it.  It  is  not  impossible  that  subsequent  modifi- 
cations in  the  time  and  manner  of  vulcanizing  may  correct  this  and 
several  other  difficulties  attendant  on  the  hardening  of  thick  masses 
of  rubber ;  meanwhile  it  is  safer  to  avoid  all  unnepessary  thickness  of 
material. .  Many  cases  will  permit  the  use  of  a  stout  aluminum  wire 
behind  and  under  the  pins,  running  along  the  incisors  and  bicuspids ; 
if  so,  it  will  reduce  the  bulk  of  rubber  and  strengthen  the  piece.  We 
often  run  a  heavy  platinum  wire  or  strip  of  doubled  plate  behind  the 
entire  arch  in  lower  sets,  to  add  to  their  weight  and  strengthen  them ; 
when  carefully  done  it  makes  a  very  strong  piece,  and  removes  the 
objection  of  lightness,  which  prevents  the  use  of  rubber  in  many  lower 
cases. 

When  the  teeth  or  blocks  are  ground,  and  the  joints  and  outside 
fitting  carefully  examined  with  a  Coddington  lens  or  some  other  strong 
magnifying  glass,  the  next  point  is  to  make  guiding  grooves  or  holes 
in  the  plaster  articulator  below  the  teeth  ;  then  place  the  lead  band 
and  pour  the  temporary  investing  rim,  as  has  been  already  described 
in  the  investment  of  teeth  for  gold  plate,  preparatory  to  backing  (see 
page  768).  If  it  is  a  partial  piece,  we  often  prefer  to  make  this  rim 
with  a  roll  of  gutta-percha,  previously  whetting  the  model  to  prevent 
its  adhesion.  An  elastic  band  or  string  will  hold  this  rim  in  place, 
while  the  wax  is  being  removed  and  substituted  by  the  matrix  plate, 
that  is,  the  wax  plate  which  is  to  be  replaced  by  the  rubber.  The  use 
of  the  rim  permits  an  examination  of  the  blocks  or  teeth  on  the  inner 
side,  and  the  correction  of  any  irregularity  in  the  pins  or  in  the  inner 
edge  of  porcelain  where  it  meets  the  rubber,  also  the  grinding  ofi"  of 
any  point  where  a  block  may  come  unnecessarily  near  the  model. 

A  small  roll  of  soft  wax  is  then  to  be  pressed  against  the  pins  and 
model,  holding  the  rim  firmly,  to  prevent  the  slightest  displacement  of 
the  blocks.  A  wax  matrix  plate  is  then  slightly  softened  and  pressed 
gently  over  the  face  of  the  model  and  the  other  wax  up  to  the  tooth. 
Be  careful  not  to  thin  the  wax  unequally,  and  yet  to  press  it  into  all 
the  natural  irregularities  of  the  model,  and  to  bring  out  the  trac- 
ings of  the  rugae  and  the  central  raphe.  If  the  first  wax  is  trimmed 
so  as  to  just  clear  the  tips  of  the  pins  and  have  a  slight  curve  where 
it  joins  the  model,  very  little  trimming  of  the  wax  plate  will  be  neces- 
sary when  blocks  are  used.  This  method  also  enables  the  operator  to 
know  exactly  the  thickness  of  the  plate  at  all  points.  Gutta-percha 
does  not  answer  so  well  as  wax,  as  it  cannot  so  readily  be  smoothed 


VULCANO-PLASTIC   WORK. 


847 


Fig.  644. 


A 


where  it  joins  the  blocks.     After   using  the  wax   knife    around  the 
edges,  it  is  well  to  go  over  the  surface  with  a  strip  of  oiled  buckskin. 

The  wax  plate  should  vary  in  thickness  from  No.  14  to  No.  18, 
gauge  plate  (Fig.  512),  according  to  the  depth  of  the  palatine  arch. 
Vulcanite  cannot  safely  be  reduced  to  the  thinness  of  gold  or  aluminum 
plates,  or  even  of  the  best  stannic  alloys.  The  elasticity  of  the  best 
made  vulcanite  is  often  thought  to  justify  great  thinness  of  plate,  and 
this  may  be  allowed  in  some  partial  pieces  ;  but  in  full  sets,  or  where 
many  teeth  lie  grouped  together,  elasticity,  with  thinness  such  as  per- 
mits bending  of  the  plate,  is  very  apt  to  cause  opening  of  joints  or 
breaking  of  blocks.  Elasticity  of  vulcanite  lessens  the  chance  of 
injury  from  an  accidental  fall ;  but  as  an  element  of  strength,  it  is 
principally  valuable  as  improving  its  rigidity  and  toughness ;  and  the 
plate  of  all  full  sets  should  be  thick  enough  to  be  unyielding  under  the 
force  of  mastication. 

Fig.  644  represents  the  ends  of  a  suit- 
able wax  spatula  or  knife.  In  flowing  wax 
with  the  heated  spatula  around  the  teeth, 
after  they  have  been  accurately  arranged 
upon  the  model, care  must  betaken  to  keep 
the  joints  free  of  it;  and  the  wax  plate 
should  be  fashioned  and  smoothed  with 
either  the  blowpipe  flame,  benzine  applied 
on  a  piece  of  soft  cloth,  or  by  the  repeated 
and  careful  application  of  the  warm  spatula. 

The  wax  plate  should  be  as  perfect  a  counterpart  of  the  vulcanite 
plate  as  it  is  possible  to  make  it.  Fig.  645  represents  a  set  of  carving 
instruments,  designed  by  Dr.  W.  W.  Evans,  for  modeling  wax  in 
vulcanite,  zylonite  and  celluloid  work. 

When  the  inside  wax  plate  has  been  completely  finished,  the  outside 
plaster  rim  is  removed,  having  provided  for  its  easy  removal  by  a 
break  or  section  opposite  the  incisors.  Again  examine  all  joints  with 
the  glass,  to  see  that  they  have  not  been  accidentally  opened  ;  then 
apply  one  or  more  strips  of  wax  to  give  the  required  form  of  edge, 
outside  the  ridge  and  above  the  blocks.  Plain  or  gum  teeth  or  blocks, 
resting  directly  on  the  gum,  must,  of  course,  have  no  wax  in  front  of 
incisors,  canines,  and  first  or  even  second  bicuspids  ;  in  all  such  cases 
be  careful,  just  before  investing  in  the  flask,  to  see  that  the  teeth  set 
closely  down  upon  the  model.  Vulcanite  blocks  have  a  shoulder 
designed  to  receive  the  margin  of  the  external  rubber  band ;  when  the 
blocks  have  been  chosen  with  such  care  that  no  grinding  of  the  upper 
edge  is  necessary,  this  gives  the  best  finish.  But  it  often  happens  that 
the  exigencies  of  the  case  require  thinning  or  shortening  of  the  blocks ; 


848 


MECHANICS. 


Fig.  645. 


a  thin  edge  of  wax  should  then  slightly 
overlap  the  blocks.  If  the  porcelain 
edge  has  sufficient  thickness,  it  is  some- 
times a  good  plan  to  bevel  it ;  the  rubber 
may  then  be  finished  continuously  with 
the  porcelain,  and  yet  have  a  retaining 
edge.  It  is  well  to  pass  a  very  fine  corun- 
dum slab  over  the  gum  just  before  placing 
the  wax  rim  ;  it  removes  accidental  rough- 
ness and  makes  the  finishing  process  easier. 
Superfluous  wax  should  be  avoided  out- 
side as  well  as  inside;  but  every  undercut 
must  be  filled,  else  there  will  be  danger 
of  breaking  thin  or  prominent  ridges  in 
separating  the  matrix.  Outside  surplus 
is  more  easily  removed  than  inside;  hence 
there  is  no  objection  in  running  the  wax 
further  up  on  the  ridge  than  the  finished 
plate ;  but  unnecessary  thickness  is  to  be 
avoided,  for  reasons  before  given. 

If  the  original  model  has  been  extended 
for  articulation,  carefully  remove  the 
plate  and  saw  ofi"  this  portion  of  the 
model,  and  trim  so  as  to  fit  the  half  flask 
in  which  it  is  to  be  set.  This  trimming 
done,  replace  the  plate,  and  fasten  it 
around  the  edges  with  a  hot  Avax  knife. 
It  is  now  ready  for  the  vulcanizing  flask. 

All  forms  of  teeth  may  be  used  with 
the  vulcanite  base,  and,  unlike  most  other 
work,  may  be  used  again  and  again. 
Continuous-gum  teeth  can  be  strongly 
and  handsomely  arranged,  provided  the 
patient  shows  but  little  of  the  tooth; 
and  also  where  celluloid  is  used  in 
connection  with  vulcanite.  Single  teeth, 
plain  or  gum,  require  either  to  be 
backed  with  gold  strips  and  soldered, 
or  simply  to  have  the  pins  lengthened. 
For  this  purpose  heavy  platina  wire,  say 
No.  20,  should  be  cut  into  lengths  from 
one-fourth  to  three-fourths  of  an  inch 
long,  set  between  the  pins  in  the  required 


VULCANO-PLASTIC   WOEK. 


849 


direction  and  soldered  with  pure  gold.  We  also  used, 
in  1858,  when  the  assortment  of  rubber  teeth  was  very 
imperfect,  plate  teeth  backed  with  a  narrow  platina 
strip,  very  similar  to  Fig.  646,  taken  from  Prof  Wild- 
man's  monograph.  The  projecting  tang  strengthens  the 
rubber  in  case  of  isolated  teeth,  and  may  be  serrated 
with  a  file ;  but  we  had  a  pair  of  forceps  with  serrated  beaks,  which 
did  this  better  and  more  quickly  than  the  file.  It  is  now,  however, 
rarely  necessary  to  resort  to  these  expedients,  unless  when  required 
to  replace  by  rubber  attachment  some  favorite  plate  tooth  which  has 
loosened.  Occasionally  some  one  or  more  under  teeth  strike  so  closely 
against  the  gum  as  almost  to  touch ;  if  rubber  is  used  in  such  cases, 
these  teeth  must  be  plate  teeth,  with  the  usual  soldered  gold  backing, 
having  a  serrated  extension  into  the  rubber. 

The  assortment  of  vulcanite  teeth  now  oflTered  to  the  profession  is, 
in  variety  of  color,  size,  and  shape,  such  as  to  meet  almost  every  pos- 
sible case.  In  fact,  we  doubt  if  the  manufacturer's  aesthetic  skill  in 
making  is  not  sometimes  in  advance  of  the  dentist's  aesthetic  ^aste  in 
selecting.  Certainly  the  stiff"  uniformity  and  monotonous  expression 
which  so  frequently  meet  the  eye  is  an  injustice  to  the  present  high 
development  of  the  dento-ceramic  art.  In  the  next  chapter  we  shall 
illustrate  by  wood-cuts,  kindly  lent  to  us  by  the  S.  S.  White  Co.,  some  of 
the  delicate  forms  which  so  exactly  imitate  Nature.  pj^^  g^y^ 

Fig.  640,  641,  642,  643,  646  and  647  will  give  a 
correct  idea  of  the  special  form  and  shape  of  the  pins 
of  vulcanite  teeth,  as  at  present  manufactured. 

Vulcanizers. — A  sixteen-horse-power  boiler,  com- 
municating by  twenty  feet  of  pipe  with  a  thirty-inch 
cubical  steam  chest,  was  the  vulcanizer  of  1857. 

The  first  one  which  was  at  all  practicable  as  an  office  fixture,  was 
a  two-chambered  affair,  of  cast  iron,  as  large  as  a  soda  fountain  reser- 
voir, heated  by  a  coal  stove.  Successive  improvements  have  since 
been  made,  and  the  vulcanizer  of  to-day  is  a  very  different  thing  from 
the  huge,  clumsy  affair  from  which  it  originated. 

The  proper  working  of  the  vulcanizer  and  the  satisfaction  with 
which.it  is  used,  depend,  in  a  great  measure,  upon  the  perfection  of 
the  workmanship  put  upon  it ;  and  a  saving  of  a  dollar  or  two  in  first 
cost,  coupled  with  the  possession  of  a  poorly-made  machine,  will  prove 
an  expensive  investment  in  the  long  run. 

Copper  is  now  almost  universally  employed  as  the  material  from 
which  the  pot,  or  body  of  the  vulcanizer  is  made ;  a  ring  of  brass 
being  brazed  to  the  edge,  to  form  the  packing  joint,  and  the  attachment 
for  the  cover.     The  flexibility  of  these  materials  render  it  important 

54 


850 


MECHANICS. 


that  the  cover  fastening  should  support  the  whole  circumference  of 
the  edge  of  the  pot  and  bring  the  strain  uniformly  upon  it,  in  order 
to  preserve  the  truth  of  the  face  of  the  packing  joint.     If  the  strain 


Fig.  649. 


is  brought  to  bear  upon  the  circumference  of  the  joint  at  intervals, 
as  when  bolt  or  clamp  fastenings  are  used,  the  result  is  that  the  pot 
gradually  yields  to  the  strain  at  the  points  where  it  is  unsupported, 
the  joint  is  drawn  out  of  true,  and  in  a  short 
time  the  vulcanizer  is  leaky  and  comparatively 
worthless.  For  this  reason,  the  screw-thread 
fastening  has  proved  most  satisfactory. 

The  Whitney  Vulcanizer,  Fig.  648,  has  a  very 
simple  fastening,  the  cover  screwing  directly  on 
to  the  pot.  Though  the  joint  is  not  absolutely 
steam  tight,  the  vulcanizer  is  capable  of  doing 
good  work.  It  is  closed  by  two  wrenches,  Fig. 
648,  h  and  c.  The  bed  plate  and  wrench,  Fig. 
648,  d  and  e,  are  preferable  where  attachment 
to  a  stationary  bench  can  be  had.  The  mistake 
is  often  made  of  oiling  the  screw  of  this  vulcan- 
izer fastening.  The  oil  will  burn  on,  causing 
the  cover  to  stick,  and  sometimes  become  almost 
immovable.     A   very   little   black   lead,  very 


VULOAJSrO-PLASTIC   WORK. 


851 


seldom  applied,  will  keep  the  packing  joint  and  thread  in  the  best 
condition.  The  error  is  more  frequently  made  of  doing  too  much 
rather  than  too  little,  in  this  direction. 

The  Hayes  Vulcanizer,  Fig.  649,  has  a  cover  which  is  placed  upon 
the  packing  joint,  and  is  secured  by  a  screw  collar  which  screws  over 


Fig.  650. 


the  edge  of  the  pot,  three  set-screws  in  which  bear  upon  the  cover,  to 
make  the  joint  steam  tight.  This  fastening,  though  more  complicated 
than  the  "Whitney,"  has  the  merit  of  obviating  any  sliding  movement 
on  the  packing  in  tightening  the  joint,  thus  increasing  the  durability 
of  the  packing,  and  of  being  absolutely  steam  tight.     To  prevent  the 


852 


MECHANICS. 


packing  from  sticking  to  the  edge  of  the  pot,  it  is  occasionally  dusted 
with  pulverized  soapstone. 

The  Hayes  "  Iron  Clad"  Vulcanizer  resembles  the  one  just  described. 
The  copper  pot,  however,  is  covered  by  a  shell  of  malleable  iron,  which 
greatly  increases  its  strength.  By  a  cold-water  test,  these  vulcanizers 
have  been  found  to  withstand  a  pressure  of  eight  hundred  pounds  to 
the  inch,  without  injury.  They  are  very  strong,  and  we  believe  there 
is  no  instance  on  record  of  the  explosion  of  a  vulcanizer  of  this 
description. 

The  Snowden  &  Cowman  Vulcanizer,  Fig.  650,  quite  recently 
introduced,  and  an  excellent  apparatus,  has  a  fastening  similar  to  the 


Fig.  651. 


Fig.  652. 


Hayes.  The  collar  has  lugs  upon  its  interior,  however,  engaging  with 
others  upon  the  pot,  thus  dispensing  with  the  screw  thread. 

The  Edson  Vulcanizer,  Fig.  651,  and  the  Woodard  Vulcanizer,  Fig. 
652,  are  so  made  that  the  flasks  can  be  closed  after  they  are  put  in  the 
vulcanizer  and  while  steam  is  rising.  In  the  Edson  Vulcanizer  this  is 
done  by  means  of  a  screw.  In  the  Woodard  a  steam  cylinder  and 
piston  form  part  of  the  vulcanizer  top,  and  the  flasks  are  closed  by  the 
rising  pressure  of  the  steam  operating  upon  the  piston.  These  vulcan- 
izers may  be  also  used  for  moulding  celluloid  plates. 

The  "  New  Mode  Heater,"  Fig.  653,  invented  by  Dr.  John  S.  Campbell, 


VULCAXO-PLASTIC    WORK 


853 


presents  many  points  of  flifference,  when  compared  with  other  vulcan- 
izers.  It  is  made  of  phosphor-bronze,  in  a  single  casting,  with  two 
chambers,  the  one  in  which  the  flask  is  placed  being  surrounded  by  an 
outer  steam  chamber.  It  has  screws  for  closing  the  flask  as  it  is  being 
heated,  and  is  adapted  to  working  celluloid  as  well  as  for  vulcanizing 
rubber.  Steam  may  be  admitted  to  the  vulcanizing  chamber  or  not, 
as  may  be  desired,  and  either  "  wet "  or  "  dry  "  heat  used.  The  use -of 
the  New  Mode  Heater,  it  is  claimed,  will  prevent  the  rubber,  when 
being  vulcanized,  from  shrinking  from   the  teeth,  and  also  permit  of 

Fig.  653. 


the  use  of  plain  teeth  with  rubber  for  the  base  and  celluloid  for  the 
gum,  a  form  of  work  to  which  the  name  of"  New  Mode  Continuous 
Gum  "  has  been  given  by  Dr.  Campbell,  the  inventor.  (See  Celluloid.) 
Fig.  654  represents  a  transverse  vertical  section  of  Dr.  Frederick 
AV.  Seabury's  improved  Vulcanizer  and  Celluloid  Press,  combined  in 
one  apparatus,  which,  it  is  claimed,  accomplishes  results  never  before 
attained  in  the  manipulation  of  both  rubber  and  celluloid,  and  in  less 
than   half  the  time  usually  required,  and  a  perfect  success  assured 


854 


MECHANICS. 


every  time.  With  this  apparatus,  cases  can  be  removed  from  the 
oven  and  others  inserted  at  any  time  during  the  process  of  vulcaniza- 
tion, with  a  delay  not  to  exceed  five  minutes,  which  is  a  great  saving 
of  time,  especially  with  repair  work.  The  drawing  also  represents  the 
improved  flask  used  in  this  apparatus  for  the  purpose  of  uniting  artifi- 
cial teeth  to  artificial  gums  under  pressure,  which  is  provided  with 


No.  2. 


guide  and  locking  pins,  the  former  inclined  at  such  an  angle  that  when 
the  upper  part  of  the  flask  is  forced  down  to  imbed  the  teeth  into  the 
gums  it  will  be  moving  at  such  an  angle  as  to  allow  the  projecting 
alveolar  ridge  to  reach  its  final  position  without  breaking  the  plaster 
investment ;  these  guide  pins  can  also  be  quickly  removed  from  the 


VULCANO-PLASTIC   WORK.  855 

flask  by  a  partial  rotation  of  the  pin.  The  locking  pins  are  so  placed 
that  the  upper  part  of  the  flask  is  forced  on  the  lower  part,  the  lock- 
pins  may  be  forced  into  place  and  thereby  lock  the  flask.  The  cover 
is  secured  by  dovetail  lockpins,  and  can  be  easily  removed.  In  the 
drawing  of  the  apparatus  No.  1,  A  designates  the  hollow  body  of  the 
vulcauizer,  which  is  supported  on  the  legs  a.  Within  this  body  is 
placed  the  boiler  B,  which  is  formed  with  the  central  inverted  trun- 
cated conical  flue  C.  The  boiler  and  flue  are  supported  by  the  tubes 
d,  which  are  connected  at  one  end  to  the  top  of  the  boiler  and  at  the 
other  end  to  the  chamber  d'\ 

D  designates  the  oven,  the  lower  end  or  base  of  which  extends  some- 
what downward  into  the  upper  end  of  the  flue  C. 

The  upper  end  of  the  oven  is  formed  with  lateral  flanges  d\  Avhich 
rest  upon  the  top  of  the  case  or  body  A,  and  thus  support  the  oven  in 
position,  and  also  form  the  top  of  the  vulcanizer. 

E  designates  the  pressure  cover  of  the  oven,  which  is  secured  in 
position  by  bolts  as  shown. 

e  e  designate  presser  screws,  which  work  through  square  threaded 
sockets  in  the  cover  and  press  upon  the  flask  F,  in  the  oven,  supported 
upon  the  disc  m. 

E^  designates  two  lids,  which  are  pivoted  upon  the  cover  in  such 
manner  as  to  be  readily  removed,  and  by  uncovering  apertures  in  the 
cover  permit  visual  access  to  the  interior  of  the  oven. 

G  designates  a  valve,  which  is  seated  in  the  flange  d^  of  the  oven,  so 
as  to  close  the  channel  d'^,  leading  from  the  pipe  d  to  the  interior  of 
the  oven. 

H  designates  a  spout;  the  outer  end  of  it  is  tightly  closed  by  the  cap 
h,  which  leads  into  the  tube  I,  entering  the  chamber  d^  from  above. 
The  purpose  of  this  spout  is  to  convey  water  to  the  boiler  B. 

i  designates  a  pop  safety  valve,  which  is  seated  on  the  upper  end  of 
the  tube  I.  J  designates  a  steam  guage  connected  by  the  siphon  cock 
j  to  the  chamber  d^  into  which  the  tube  d  opens. 

K  designates  a  test-cock  communicating  with  the  chamber  d^,  and  b 
designates  a  similar  cock  communicating  with  the  boiler  B,  on  the 
water  level. 

In  using  this  vulcanizer  a  gas  or  gasoline  burner  is  set  beneath  the 
boiler  B,  and  the  valve  G  is  closed ;  but  the  test-cock  K  is  not  closed 
until  the  escaping  steam  shows  that  all  of  the  air  is  out  of  the  boiler. 
The  heat  from  the  burner  will  ascend  through  the  flue  C,  and  will  act 
directly  upon  the  bottom  and  sides  of  the  oven,  thus  heating  the  oven 
and  water  which  has  been  previously  placed  in  the  boiler  at  the  same 
time  or  separately. 

No.  2  illustrates  a  vertical  section  of  the  solid  cover  which  is  used 


856 


MECHANICS. 


at  all  times,  except  when  closing  the  flask,  and  occupies  the  same 
position  on  the  vulcanizer  as  the  pressure-cover  E.  It  is  provided 
with  a  very  sensitive  thermometer,  immersed  in  a  mercury  bath  d, 
which  projects  into  the  oven  D,  and  a  test-cock  v,  used  to  let  the  air 
out  of  the  oven  before  vulcanizing,  and  to  blow  the  steam  out  through 
after  vulcanizing. 

The  bar  wrench  is  to  be  used  on  the  cover  bolts  only,  and  must 
never  be  used  on  the  presser  screws  e  e,  for  which  the  T  wrench  is 
provided. 

Figs.  655  and  656  represent  Dr.  W.  W.  Evans'  New  Vulcanizer  and 


Fig.  655. 


Fig.  656. 


Celluloid  Apparatus  combined,  which  is  claimed  to  possess  superior 
qualities  for  vulcanizing  rubber  and  moulding  celluloid  and  zylonite. 

Fig.  656  shows  a  front  elevation  with  top  attached  and  tools  needed 
in  the  working  of  this  apparatus. 

Fig.  655  illustrates  a  transverse  vertical  section  with  one  flask  in 
position.  A  is  a  light  casing,  B  the  boiler,  composed  of  two  separate 
cups  b  b,  united  concentrically  by  screws  b^  to  form  a  water  and  steam 
space.  The  bottom  of  the  boiler  A  is  partly  concave,  to  facilitate 
ebullition  and  keep  the  steam  in  a  state  of  agitation.  D  illustrates 
the  oven  composed  of  the  inner  cups  b,  having  a  cover.  C  is  an  inlet 
for  steam,  d,  through  the  cup  b,  from  the  boiler,  and  an  exit  for  steam 
through  the  cover  d^  both  openings  being  controlled  by  valves  d^  and 


VULCANO-PLASTIC   WOEK.  857 

d'.  E  E  represent  the  bolts  with  spherical  heads  at  c,  the  point  of 
contact  with  the  cover  C,  which  has  a  corresponding  socket  to  receive 
it,  thus  making  a  steam-tight  joint.  The  top  of  the  head  c'^  is  made  to 
fit  the  T  wrench,  that  also  fits  the  difi^erent  valves.  To  gain  more 
pressure  than  is  usually  required,  an  additional  sexangular  portion  c^ 
has  been  made,  whereby  any  amount  of  pressure  can  be  exerted.  The 
lo\ver  portion  of  the  bolt  is  threaded  for  one-half  its  distance,  and 
screws  into  or  through  the  platen  F,  which  is  drawn  toward  the  top  by 
turning  the  bolts  to  the  right,  thus  closing  the  flasks  G  with  facility, 
and  without  any  strain  upon  the  boiler,  f  is  the  thermometer,  on 
either  side  of  which  are  the  valves,  one  connecting  the  boiler  with  the 
oven ;  the  other  a  conical  safety  valve,  so  arranged  that  the  steam  in 
the  boiler  can  never  go  higher  than  the  point  at  which  the  safety  valve 
is  set.  I  is  a  handle  to  remove  the  top.  Two  large  flasks  may  be 
used  at  a  time,  and  it  is  claimed  that  it  will  readily  stand  from  250  to 
300  pounds  pressure.  It  is  also  claimed  that  rubber  vulcanized  in  this 
apparatus  is  much  more  elastic,  denser  and  tougher,  and  retains  its 
color  better  than  by  other  processes,  and  that  it  will  not  shrink  from 
the  teeth,  and  can  be  vulcanized  in  thicker  masses  without  becoming 
porous.  For  celluloid  and  zylonite,  better  results,  shorter  time  of 
moulding  (one  hour  and  a  half)  and  no  lost  steam  from  the  boiler,  are 
claimed. 

The  mercurial  thermometer  is  now  almost  universally  employed  to 
indicate  the  temperature  of  the  vulcanizer.  It  is  a  simple  and  con- 
venient device,  and  when  protected  from  the  action  of  steam  upon  the 
glass  bulb,  by  immersing  it  in  the  "  Mercury  Bath  "  (the  invention  of 
the  late  Dr.  Geo.  E.  Hayes),  it  has  a  fair  durability.  If  accidentally 
broken,  it  can  be  easily  replaced  at  a  small  expense.  It  must  be 
remembered,  however,  that  it  only  indicates  the  temperature  of  its 
bulb,  and  the  parts  immediately  surrounding  it,  which  may  be  different 
from  that  of  the  interior  of  the  vulcanizer.  If  a  thermometer  and 
steam  gauge  are  attached  to  the- same  vulcanizer,  a  discrepancy  of  as 
much  as  twenty  degrees  will  be  found  at  times  in  their  indications, 
varying  with  the  amount  of  air  included  in  the  vulcanizer  in  closing 
it.  This  statement  is  proved  by  the  fact  that  when  the  air  is  expelled 
by  blowing  off*  a  little  steam,  the  gauge  and  thermometer  w^ill  always 
agree. 

The  uncertainty  as  to  the  results  attained  in  different  vulcanizations 
is  thus  accounted  for.  To  obtain  uniformity  the  air  must  be  expelled 
from  the  vulcanizer.  If  there  is  no  cock  for  letting  off"  steam,  the  vul- 
canizer should  only  be  closed  after  the  water  in  it  is  boiling ;  the 
cover  being  placed  loosely  upon  it,  and  allowed  to  remain  so  until  steam 
issues  freely  from  under  it.     The  joint  should  then  be  tightened  as 


858 


MECHANICS. 


expeditiously  as  possible.  There  being  now  an  atmosphere  of  pure 
steam  above  the  water  in  the  vulcanizer,  the  heat  will  be  equal  in  all 
parts  of  it,  and  the  indications  of  the  thermometer  will  be  correct. 

Care  should  be  taken  that  the  mercury  bath  has  enough  mercury  in 
it  to  insure  contact  with  the  bulb  of  the  thermometer ;  an  air  space 
between  the  bulb  and  vulcanizer  cover  will  be  as  fatal  to  correct  indi- 
cations as  in  the  former  case. 

A  steam  gauge  would  be  a  very  desirable  indicator  of  the  temper- 
ature, if  it  were  not  for  its  first  cost,  and  the  annoyance  caused  by  the 
necessity  for  its  connection  to  and  removal  from  the  vulcanizer  each 

time  it  is  used. 

Fig.  657. 


The  vulcanizer  is  usually  heated  by  either  gas,  alcohol,  or  kerosene. 
Gas,  if  used  in  a  burner  which  will  mix  the  proper  quantity  of  air 
with  it  before  burning,  is  the  most  convenient,  cleanest,  and  probably 
the  cheapest  fuel  for  the  purpose.  The  flame  should  be  a  clear  blue, 
with  no  streaks  of  yellow.  A  yellow  flame  results  from  an  insufficient 
mixture  of  air,  and  makes  smoke,  soot,  and  a  bad  smell,  from  the  pro- 
duction of  acetylene.  The  use  of  gas  also  admits  of  the  employment 
of  the  gas  regulator  (Fig.  657),  an  attachment  which  automatically 
keeps  the  temperature  of  the  vulcanizer  at  the  exact  point  required. 
The  steam  pressure  acts  upon  a  valve  to  control  the  flow  of  gas  to  the 


VULCANO-PLASTIC   WORK. 


859 


burner,  lessening  the  flow  as  the  pressure  rises,  and  keeping  it  at  the 
point  for  which  it  is  set.  It  is  not  liable  to  get  out  of  order,  and  with 
it  the  supervision  of  the  dentist  over  the  vulcanizing  process  is  not 
required  ;  and  if  the  time  cut-off  is  also  used,  the  dentist  is  at  liberty 
to  go  to  his  patients  in  the  operating  room,  without  the  necessity  of 
giving  a  thought  to  the  vulcanizer,  knowing  that  the  temperature  will 
be  kept  exactly  right,  and  that  the  gas  will  be  turned  off  at  the  right 
time.  The  results  will  thus  be  uniform  ;  much  more  so  than  is  possible 
with  the  use  of  the  thermometer,  as  the  regulator,  operating  by  steam 
pressure,  is  more  sensitive  and  exact  than  the  thermometer  can  possibly 
be.  After  gas,  the  alcohol  flame  is  preferable  for  vulcanizing  pur- 
poses. It  is  clean  and  inoffensive.  Many  use  the  kerosene  stove,  but 
taking  into  account  its  smoke  and  smell,  it  may  be  doubted  whether 
the  economy  secured  by  its  use  is  not  dearly  bought. 

The  following  tables,  carefully  collated  from  experiments  of  the 
French  Academy,  the  Franklin  Institute,  Ure,  Dalton  and  others,  will 
serve  as  a  guide  in  the  use  of  either  the  steam-gauge  or  the  mercurial 
thermometer : — 


No.l. 

No.  2. 

Pressure  per  Square  Inch. 

Temperature. 

Pounds. 

Inches  of 
Mercury. 

Atmos- 
pheres. 

Pounds 
Avoirdupois. 

Scale, 
Fahrenheit. 

Differences. 

Temperature. 

30 
60 
90 
120 
150 
180 
210 
240 
270 
300 

360 
420 
480 
540 
600 
660 
720 

1 
2 
3 
4 
5 
6 
7 
8 
9 
10 

12 
14 
16 
18 
20 
22 
24 

15 

30 

45 

60 

75 

90 

105 

120 

135 

150 

180 
210 
240 
270 
300 
330 
360 

212° 
250° 
275° 
294° 
309° 
321° 
332° 
342° 
352° 
360° 

374° 
387° 
398° 
409° 
419° 
428° 
486° 

38° 
25° 
J  9° 
15° 
12° 
11° 
10° 
10° 
8° 

14° 

13° 
11° 

11° 
10° 

9° 
8° 

63 

73 

80 

87 

95 

102 

110 

117 

124 

131 

300° 
310° 
315° 
320° 
325° 
330° 
3f5^ 
340° 
345° 
350° 

These  tables  show  the  increase  of  steam  pressure  Avith  the  tempera- 
ture, up  to  a  point  much  higher  than  the  dental  vulcanizer  should 
ever  be  called  upon  to  bear.  The  second  table  is  prepared  especially 
to  show  the  pressure  due  to  the  temperature  at  different  vulcanizing 
points,  and  attention  is  especially  called  to  the  rapid  increase  of  pres- 


860  MECHANICS. 

sure  with  equal  increments  of  heat  as  the  temperature  rises.  The  last 
column  in  Table  No.  1  shows  the  additional  temperature  required  for 
equal  increments  of  pressure,  and  it  will  be  seen  that  while  it  requires 
38°  to  raise  the  pressure  fifteen  pounds  at  212°,  only  4°  is  required 
for  the  same  increase  from  430°.  The  pressure  nearly  doubles  with 
the  addition  of  each  50°  of  heat,  and  the  allowing  a  vulcanizer  to 
run  up  to  400°  or  420°  is  shown  to  be  a  piece  of  unpardonable  care- 
lessness, and  a  proceeding  fraught  with  the  greatest  danger  to  life  and 
property. 

Every  vulcanizer  should  be  provided  with  some  means  by  which  the 
steam  will  be  allowed  to  escape  before  the  danger  point  is  reached. 
Safety  valves  have  been  thoroughly  tried,  and  have  proved  unsatis- 
factory, from  their  constant  leakage.  The  fusible  plug,  consisting  of 
an  alloy  of  soft  metal  filling  a  hole  in  the  vulcanizer,  which  would 
melt  and  blow  out  at  850°  or  360°  was  at  one  time  much  used,  but  it 
has  the  fatal  defect  of  hardening  after  repeated  heating,  so  that  its 
melting  point  is  raised  to  400°  or  even  more  ;  so  that  after  being  used 
a  short  time  it  is  wholly  untrustworthy.  The  most  satisfactory  device 
for  the  purpose  is  the  copper  disk  (Fig.  658),  made  of 
65  8  metal  thin  enough  to  give  way  under  an  extreme  pres- 
sure. It  is  secured  upon  the  end  of  a  small  stud, 
screwed  into  the  vulcanizer  cap,  by  means  of  a  washer 
and  screw-cap.  Long  use  does  not  impair  the  efficacy 
of  this  device,  and  no  instance  has  yet  occurred  of  an 
explosion  where  it  has  been  applied  to  the  vulcanizer 
and  was  in  good  order.  Strange  to  say,  there  are  those 
foolhardy  enough  to  deliberately  plug  it  up,  and  destroy 
its  usefulness,  because  it  has  given  way  and  warned 
them  of  their  carelessness. 

As  the  copper  disk  gives  way  from  over-pressure,  it  sometimes  does 
so  before  the  thermometer  has  reached  320°.  If  this  is  the  case,  it  is 
probably  because  the  vulcanizer  has  been  filled  too  full  of  water. 
Allowance  should  always  be  made  for  the  expansion  of  water  by  heat ; 
and  at  least  one  inch  in  height  should  be  left,  when  the  vulcanizer  is 
filled,  for  expansion,  and  for  steam  room.  An  instance  is  on  record 
of  a  Whitney  vulcanizer,  with  the  fusible  plug,  being  stretched  by 
successive  heatings  when  full  of  water,  so  that  its  diameter  was 
increased  nearly  a  quarter  of  an  inch.  In  doing  this,  it  was  subjected 
to  a  strain  of  nearly  five  hundred  pounds  to  the  inch,  and  without 
heating  it  above  320°.  The  blowing  out  of  the  disk  at  an  apparently 
low  temperature  may  occur  from  applying  a  strong  heat  to  the  vulcan- 
izer when  it  has  very  little  water  in  it,  the  water  absorbing  the  heat, 
and   the  pressure   rising  before  the  heat  is  conducted  to   the   ther- 


VULCAN 0-PLASTIC   WORK. 


8G1 


mometer,  so  that  it  can  give  the  correct  indication.  All  experiments 
in  vulcanizing  show  that  the  best  results  are  obtained  when  the  tem- 
perature rises  very  gradually,  and  with  some  samples  of  rubber,  and 
especially  if  some  parts  of  the  plate  are  unusually  thick,  a  rapid 
heating  is  sure  to  cause  spongy,  porous  places  in  the  plate,  and  neces- 
sitates its  being  made  over.  Repeatedly  tightening  and  loosening  the 
cap  upon  the  disk,  as  by  using  it  for  letting  off  steam,  will  cause  its 
failure  ;  or  tightening  it  with  too  much  force.  It  is  only  necessary 
that  it  should  be  steam-tight ;  and  the  copper  is  so  thin  and  delicate 
that  unnecessary  force  will  damage  it. 

Fig.  659. 


Flasks. — Of  flasks  there  are  several  varieties,  many  of  which  are 
open  to  some  objections.  The  essentials  of  a  good  flask  are :  1.  It 
must  have  depth  and  width  for  the  largest  cases.  2.  Both  ends  should 
be  separate,  for  greater  convenience  of  placing  the  model  in  either  ring. 

3.  The  guide  flanges,  about  one-quarter  of  an  inch  long,  should  work 
straight  and  true,  be  strong,  and  yet  not  unnecessarily  break  the  regu- 
larity of  inside  and  outside  surfaces;  cover  flanges  may  be  very  short. 

4.  Inside  and  outside  should  present  as  unbroken  a  surface  as  possible, 
for  facility  in  removing  and  cleaning  ofi"  surplus  plaster.     Both  rings 


862 


MECHANICS. 


should  taper,  partly  to  give  greatest  breadth  to  the  line  of  junction, 
partly  for  easier  delivery  of  plaster. 

Figs.  659  and  660  represent  the  "  Star  "  and  "  Anchor  "  flasks,  the 
first  being  reversible;  other  flasks  are  also  self-locking,  by  means  of 
flat  springs  on  the  outside  of  the  lugs. 

Fig.  660. 


Fig.  661  represents  the  "box  flask,"  designed  for  extra  large  cases, 
splints  for  fractures,  artificial  palates,  etc. 


Fig.  661. 


Making  Matrix,  Removing  Wax,  and  Packing  the  Rubber. — The  model 
of  a  lull  set  is  placed  in  the  shallow  half,  A,  of  the  flask  (Fig.  662), 
with  wax  plate  and  teeth  attached,  as  before  described.  The  model 
must  be  saturated  with  water,  to  prevent  the  too  rapid  setting  of  the 


VULCANO-PLASTIC  WOEK. 


863 


plaster  batter  with  whicb  the  flask  is  partly  filled,  and  which,  on  plac- 
ing the  model,  rises  to  edge  of  flask  and  edge  of  the  wax  plate.  The 
plaster  should  be  mixed  as  thick  as  will  pour  readily,  and  the  lower 
section  of  the  flask  partly  filled  with  it,  when  the  model  and  teeth  should 
be  placed  in  it,  bottom  down,  as  shown  in  Fig.  662,  A,  and  slightly  in- 
clining in  front,  so  as  to  exclude  all  air  bubbles  when  forcing  it  into 
place.  In  the  case  of  an  entire  upper  or  lower  set  the  plaster  should 
extend  up  to  the  wax,  as  this  will  allow  the  teeth  to  be  imbedded  in 
the  plaster  filling  the  upper  section  of  the  flask.  As  soon  as  the  plas- 
ter has  become  moderately  firm,  trim  smoothly  up  to  the  model,  with 
spatula  and  sponge  ;  then  soap  this  surface,  or  varnish  and  oil  it,  or 
cover  it  with  tin-foil.  When  shellac  varnish  is  used,  care  should  be 
taken  that  the  teeth  or  gums  are  not  coated  with  it.  Some  prefer  the 
soap  solution,  white  soap,  5j,  soft  water,  Oj,  for  separating  plaster 
surfaces.  Some  are  in  the  habit  of  placing  the  lower  half  of  the  flask 
in  water,  that  it  may  absorb  as  much  as  possible  before  the  upper  half 
is  poured.     Mix  a  fresh  lot  of  rather  stiff'batter,  and  brush  it  carefully 

Fig.  662. 


over  the  wax  and  into  all  the  interstices  of  the  teeth.  Then  place  the 
upper  half-flask,  C,  accurately  upon  the  lower  half,  and  quickly  pour 
the  batter,  stirring  it  well,  with  a  feather,  into  the  space  between  the 
teeth  and  sides  of  the  flask.  Set  on  the  cover  D,  and  apply  the  clamp 
B,  or  a  heavy  weight.  Before  it  fully  hardens,  wash  off"  the  plaster 
with  a  sponge,  from  the  outside  of  the  flask,  and  let  it  get  quite  hard 
before  separating  the  two  halves.  The  object  of  making  the  batter 
stiff"  is  to  give  it  greater  hardness,  for  support  of  the  blocks  under 
pressure  of  packing.  These  are  often  displaced,  and  the  joints  opened 
under  moderate  pressure  ;  because,  first,  the  batter  is  too  thin,  and, 
secondly,  time  is  not  allowed  for  it  properly  to  harden  before  packing. 
The  flask  should  be  set  in  water  at  about  120°,  for  five  minutes  before 
separation,  so  that  in  case  of  undercut  or  of  a  thin  or  prominent  ridge, 
there  shall  be  no  danger  of  breaking  the  model.  Dry  heat  may  also 
be  used  to  separate  the  flask,  but  the  wet  is  preferable,  as  the  former 
may  melt  the  wax  and  cause  it  to  be  absorbed  by  the  plaster ;  and  if 
the  base  plate  is  gutta-percha,  it  will,  if  made  too  hot,  adhere  to  the 


864 


MECHANICS. 


model.  The  wax  or  gutta-percha  model  plate  should  be  removed 
entire,  if  possible,  and  also  the  wax  around  the  pins,  by  means  of  a 
small  excavator,  and  what  remains  may  be  washed  away,  by  pouring 
over  the  surface  a  stream  of  boiling  water,  from  a  height  of  about  one 
foot.  All  wax  should  be  carefully  removed  in  order  to  prevent  dete- 
rioration of  the  rubber,  and  as  much  of  it  as  possible  be  preserved  for 
the  purpose  of  determining  the  quantity  of  rubber  necessary  to  use  in 
packing  the  piece.  After  the  wax  is  entirely  removed,  vents  or  gates 
are  cut  in  the  plaster  surface  of  the  investment  as  shown  in  Fig.  666, 
to  allow  the  excess  of  rubber  to  escape  when  the  flask  is  closed.  The 
flasks  will  then  present  the  appearance  shown  in  Fig.  663 ;  the  model- 
half,  E,  separating  from  the  teeth  and  wax  contained  in  the  dental- 
half,  H.  Should  the  joints  not  be  very  closely  fitted,  place  a  little  dry 
plaster  over  each,  and  touch  with  a  drop  of  water  or  diluted  soluble 
glass,  and  when  hard,  trim  ofi"  the  surplus  plaster.  Some  prefer  to 
pack  with  tin  or  gold  foil.  The  zinc  cement,  in  the  form  of  the 
oxychloride  or  oxyphosphate,  is  also  serviceable,  and  when  used  for 

Fig.  663. 


such  a  purpose  should  be  mixed  quite  thin  and  allowed  to  become  as 
hard  as  possible.  Without  some  such  precaution,  the  rubber  will 
press  into  open  joints,  and  present  an  unsightly  appearance ;  of  course, 
closely  ground  joints  are  preferable  to  any  of  these  expedients :  but 
neither  the  tightest  joints  nor  any  precautions  will  avail,  if  strong 
pressure  is  used  in  packing,  for  this  invariably  opens  the  joints  and 
admits  the  gum. 

In  partial  cases,  or  where  no  vulcanite  is  required  outside  the  arch 
and  above  the  teeth  (where  plain  teeth  are  used,  resting  directly  upon 
the  gum),  the  deep  half,  H,  must  be  used  for  the  model,  and  the  line  of 
separation  be  made  at  the  cutting  edges  of  the  teeth  ;  so  that  the  plas- 
ter around  the  teeth  may  come  nearly  or  quite  level  with  the  edge  of 
the  flask.  The  teeth  are  thus  firmly  fixed  in  their  exact  position,  and 
resist  displacement,  which  the  separation  of  the  flasks  or  the  pressure 
of  the  rubber  might  possibly  occasion.  In  this  way,  should  the  flasks 
chance  not  to  come  perfectly  together,  the  result  will  be  an  extra 


VULCANO-PLASTIC   WORK. 


865 


thickness  of  plate,  but  no  displacement  of  teeth.  We  consider  this  use 
of  the  deep  half  of  the  flask,  in  all  partial  cases,  as  of  utmost  import- 
ance. The  teeth  are  never  disturbed  in  their  position  on  the  model 
given  them  in  the  wax  plate ;  also,  there  is  no  breaking  of  plaster 
teeth  or  splitting  of  the  model  by  pressure  of  the  rubber. 

To  prevent  the  rubber  from  adhering  to  the  surface  of  the  plaster 
model  and  mould,  which  gives  a  rough  surface  to  the  palatine  portion  of 
the  plate,  this  surface,  as  before  remarked,  should  be  coated  with 
either  liquid  silex,  collodion,  or  tin  foil.  When  liquid  silex  is  used, 
a  thin  coat  upon  a  moist  plaster  surface  answers  best ;  collodion  is  ap- 
plied like  liquid  silex  ;  tin  foil  is  attached  to  the  plaster  surface  by 
means  of  shellac  varnish,  and  carefully  adapted,  by  pressure  with  a  soft 
cone  of  leather,  to  all  the  inequalities,  and  its  surface  is  coated  with 

Fig.  G64, 


collodion,  which  is  allowed  to  dry,  when  it  is  again  coated  with  the 
soap  solution.  Such  a  method  will  render  it  easy  to  remove  the  tin 
from  the  vulcanized  rubber,  and  give  a  polished  surface.  Without 
such  precaution  the  use  of  muriatic  acid  may  be  necessary  in  order  to 
remove  the  tin  foil.  Gilding  the  surface  of  the  model  with  gold  foil  is 
also  done. 

Clean  hands  and  instruments  are  very  necessary  in  packing  rubber, 
otherwise  the  color  and  even  the  texture  of  this  material  are  impaired. 
The  mould,  as  well  as  the  rubber,  should  be  warm  during  the  packing 
process,  and  the  latter  should  be  cut  in  different-sized  pieces,  using  a 
large  piece  of  the  proper  shape  to  cover  the  palatine  surface  of  the 
model,  and  which  may  be  applied  by  pressure  with  the  thumb  and 
fingers,  first  dipping  them  in  water.     Fig.  664  represents  a  boiler  suit- 

55 


866 


MECHANICS. 


able  for  heating  the  flasks,  and  having  a  flat  top  on  which  the  rubber 
may  be  softened.  In  packing  the  smaller  pieces  of  rubber,  and  especially 
the  long  strips  suitable  for  the  rim  of  the  plate,  care  is  necessary  that 
all  particles  of  plaster  be  excluded,  and  also  that  too  much  rubber  is 
not  pressed  against  thin  margins  of  the  gum  ;  otherwise  fracture  of 
the  porcelain  blocks  may  result,  when  the  flask  is  being  closed.  It  is 
safer  to  pack  the  rubber  thicker  in  the  centre,  and  as  it  yields  to  the 
pressure  it  will  flow  around  weak  points  without  danger  of  fracturing 

Fig.  665. 


them.  Each  piece  of  rubber  as  it  is  added  should  be  consolidated ; 
and  if  any  tooth  or  block  has  become  loosened  in  the  plaster  a  drop  of 
liquid  silex  placed  in  the  bottom  of  its  plaster  cavity  will,  after  it 
becomes  dry,  hold  it  firmly  in  place. 

It  is  desirable  in  all  cases,  and  quite  essential  in  most,  that  the  flasks 
should  come  perfectly  together.  This  is  accomplished  by  attention  to 
three  points :  1.  Softening  the  rubber ;  2.  Using  a  proper  quantity  ;  3. 


VULCANO-PLASTIC  WORK.  867 

Having  vents  for  the  surplus.  First,  for  softening  the  rubber,  use  a 
deep  covered  saucepan,  capable  of  holding  the  flask  press  and  contain- 
ing two  or  three  inches  of  water.  When  the  flask  is  thoroughly  heated 
by  the  steam,  the  rubber  is  placed  on  the  cover  of  the  saucepan,  or  on 
a  small  shelf  attached  to  the  inside  of  the  saucepan  ;  then,  while  soft, 
let  it  be  packed,  with  the  help  of  a  pointed  stick,  into  the  dental  half 
of  the  matrix.  Around  the  teeth  the  rubber  may  be  packed,  in  the 
form  of  very  narrow  strips,  with  a  flattened  point  of  hard  wood,  some- 
what as  foil  is  inserted  into  the  cavity  of  a  tooth,  or  with  instruments 
made  from  excavators  with  blunt  points  bent  at  a  right  angle.  The 
remainder  is  packed  either  in  large  strips  or  in  one  piece  cut  to  the 
shape  of  the  wax  plate. 

Secondly.  It  is  important  to  use  the  proper  quantity  of  rubber  ;  too 
little  vulcanite  spoils  the  piece ;  too  much  requires  a  pressure  which 
may  break  the  blocks,  displace  the  teeth,  and  force  rubber  into  the 
joints ;  or  else  requires  a  long  time  for  a  safe  degree  of  pressure  to 
bring  the  flask  together.  In  some  cases  the  quantity  can  be  correctly 
found  by  having  the  sheets  of  vulcanite  exactly  as  thick  as  the  wax 
plate,  removing  the  latter  as  carefully  as  possible  and  marking  off"  its 
size  on  the  former.  But  for  some  irregularly-shaped  cases  and  most 
lower  cases,  the  following  simple  method  will  be  found  better.  Let  the 
plate  be  entirely  of  wax  ;  remove  it  all  from  the  matrix,  and  roll  it 
into  a  sheet  the  thickness  of  the  rubber ;  make  the  rubber  a  little 
larger  than  the  wax  ;  then  cut  into  conveniently-sized  strips  and  pack, 
putting  most  at  those  points  where  the  wax  was  thickest.  Starr's 
measuring  glass,  which  determines  the  quantity  of  rubber  by  "  dis- 
placement," is  a  convenient  instrument  for  this  purpose.     (Fig.  665.) 

For  ascertaining  the  quantity  of  rubber  required  for  any  given 
case:  The  vessel  being  about  half  filled  with  water,  set  the  lower 
pointer  to  the  level  of  the  water ;  throw  in  every  particle  of  the  model 
plate;  set  the  upper  pointer  to  the  rise  of  the  water ;  empty  the  vessel, 
and  again  fill  with  water  to  the  lower  pointer  ;  add  a  sufiicient  quantity 
of  rubber  to  cause  the  water  to  rise  to  the  upper  pointer,  and  there 
will  be  just  enough  to  fill  the  mould.  'Allowance  can  then  be  made 
for  surplus. 

Thirdly.  Since  the  error  in  quantity  should  always  be  on  the  safe 
side  of  excess,  provision  must  be  made  for  the  escape  of  this  surplus  by 
cutting  vents,  that  the  halves  of  the  matrix  may  come  together  with- 
out too  great  pressure.  Fig.  666,  taken  from  Prof.  Wildman's  mono- 
graph, is  a  fine  illustration  of  the  best  method  of  cutting  these  vents. 
The  radiating  vents  might,  however,  stop  at  the  circular  groove,  taking 
care  to  make  this  large  enough  for  any  possible  excess  of  rubber.  If 
these  leaders  are  too  large  next  the  plate,  the  rubber  may  not  pack  so 


868 


MECHANICS. 


firmly  as  is  desirable;   also,  the  generation  of  gas,  Avhile  vulcanizing, 
may  force  rubber  too  freely  into  the  groove,  and  so  make  it  porous. 


Fig.  666. 


Fig.  667. 


A  good  form  of  flask  press  is  that  of  Messrs.  Snowden  &  Cowman,  Fig. 

667.  As  soon  as  the  rubber  is  packed,  the  halves  of  the  flask  are  care- 
fully brought  together,  placed  in  the  press,  and  a 
moderate  force  applied  ;  the  press  and  flask 
are  then  placed  in  the  heater.  A  piece  of  pure 
"rubber-packing,"  about  an  inch  thick,  placed 
under  the  screw,  will,  as  before  stated,  insure 
a  constantly  acting  force  whilst  in  the  heater. 
Avoid  using  the  full  power  of  even  one  hand 
upon  the  lever ;  if  the  vents  are  free,  and  great 
excess  of  material  is  avoided,  moderate  pressure 
acting  steadily  in  the  heater  will  safely  bring 
any  flask  together  in  from  ten  to  forty  minutes. 
In  all  cases  use  a  flask  press  (Fig.  667)  first, 

and  the  small  screw  bolts  when  the  case  is  ready  for  the  vulcanizer. 

If  pressure  is  applied  suddenly,  before  the  rubber  is  sufiiciently  plastic, 

there   is   great   danger   of  fracturing   the   teeth,  especially  sectional 


VULCANO-PLASTIC  WORK.  869 

blocks.  When  the  screw  bolts  alone  are  used  to  bring  the  sections  of 
the  flask  together,  no  more  pressure  should  be  applied  at  first  than  can 
be  made  with  the  fingers,  after  which  the  flask  is  placed  in  boiling 
water  for  a  few  minutes,  when  a  gentle  turning  of  the  screws  will 
suffice  to  bring  the  parts  together.  Clean  flasks  are  essential  to  suc- 
cessful packing ;  for  soiled  fingers  stain  the  rubber,  which  interferes 
with  perfect  union  of  the  pieces ;  hence  all  apparatus  handled  in 
packing  should  be  so  simple  in  form  as  to  be  readily  cleaned  ;  also, 
it  is  well  to  keep  them  constantly  covered  with  a  coating  of  varnish. 

Time  of  Vulcanizing. — When  the  halves  of  the  flask  are  brought 
into  contact,  it  is  taken  from  the  press,  the  screws  are  adjusted,  and 
it  is  placed  in  the  vulcanizer,  which  is  then  filled  two-thirds  full  of 
boiling  water,  the  cover  adjusted,  the  gas  or  lamp  lighted,  and  time 
reckoned  from  the  moment  of  closing  the  cover. 

The  time  occupied  in  heating  up  and  vulcanizing  varies  with  difierent 
varieties  of  rubber — from  fifteen  minutes  to  one  hour  and  a  half  As 
thermometers  vary  much,  and  the  rubber  used  also  varies,  the  best 
plan  is  for  every  one  to  vulcanize  trial  pieces  until  the  required  hard- 
ness, toughness  and  elasticity  are  obtained.  It  should  curl  under  the 
scraper  like  horn,  permit  bending  at  an  angle  of  at  least  45°,  and 
return  to  its  original  shape  unchanged. 

When  the  heat  is  too  great,  or  the  time  too  long,  the  rubber  becomes 
dark  and  brittle.  For  the  black  rubber  a  longer  time  is  necessary 
thati  for  the  red  rubber,  and  the  best  method  is  to  heat  up  very  slowly 
until  it  has  reached  320°  F.,  or  to  use  a  less  heat  and  longer  time. 
The  more  foreign  matters  rubber  contains  the  less  time  is  required  to 
vulcanize  it;  and  where  the  adulteration  is  considerable,  as  in  the  case 
of  the  pink  rubber,  the  heat  may  be  raised  more  rapidly,  but  such 
rubbers  are  weak  and  unfit  for  forming  any  more  of  the  plate  than 
the  gum  portion.  In  using  the  red  rubbers,  the  heat  should  not  rise 
higher  than  320°,  and  the  piece  should  be  allowed  to  stand  until  it 
is  cold. 

In  a  very  large  proportion  of  vulcanite  pieces,  the  full  strength  of 
the  material  is  lost  by  overheating ;  in  others,  by  the  opposite  error 
of  giving  too  much  elasticity  and  throwing  undue  strain,  in  full  cases, 
upon  the  blocks  and  the  rim  of  rubber  behind  them.  If  some  of  the 
time  spent  in  polishing  up  vulcanite  and  bringing  out  the  ofiensively 
glaring  brilliancy  of  its  color  were  devoted  to  careful  management  of 
the  vulcanizer,  to  making  proper  record  of  heatings,  so  as  to  arrive  at 
uniform  results,  and  to  the  cultivation  of  those  habits  of  accuracy 
■which  alone  can  give  success,  there  would  be  fewer  broken  pieces 
returned  to  the  laboratory  for  repair. 

Slow  heating  and  a  perfectly  tight  vulcanizer  full  of  water,  with 


870  MECHANICS. 

flask  well  bound  together  and  vents  not   too  free,  are  the  best  safe- 
guards against  porous  rubber. 

It  sometimes  happens,  when  large  and  thick  masses  are  built  upon 
the  plate,  as  in  cases  of  excessive  absorption,  that  the  thick  portions  of 
the  plate,  when  vulcanized,  prove  to  be  soft  and  spongy  in  the  centre. 
This  is  the  result,  first,  of  bringing  the  plate  up  to  the  vulcanizing 
point  too  quickly,  and  the  retention  of  the  sulphurous  gas.  A  long 
time,  even  two,  three  or  four  hours,  the  time  depending  upon  the 
thickness  of  the  mass  of  rubber  to  be  hardened,  should  be  taken  to 
raise  the  temperature  of  the  vulcanizer  from,  say  250°  to  320°. 
Second.  Different  samples  of  rubber  act  differently  when  vulcanized 
in  thick  masses,  depending  somewhat  upon  the  amount  of  earthy 
matter  contained  in  them.  It  is  very  difficult  to  vulcanize  a  mass 
of  pure  rubber  and  sulphur  even  three-eighths  of  an  inch  thick, 
and  insure  its  solidity.  On  the  other  hand,  some  of  the  English  pink 
rubbers,  which  contain  large  amounts  of  oxide  of  zinc  and  vermilion, 
can  be  vulcanized  in  thick  masses  with  but  little  trouble.  It  is  to  be 
remarked,  also,  that  rubbers  which  are  "  loaded  "  with  earthy  matter 
have  less  shrinkage  than  those  which  are  purer. 

So,  the  expedient  may  be  resorted  to,  of  packing  the  inside  of  thick 
portions  of  the  plate  with  some  one  of  the  rubbers  containing  more 
earthy  matter  than  those  usually  employed.  Another  expedient  is,  to 
fill  in  parts  of  the  mould  where  the  thickness  of  rubber 'is  excessive 
with  a  mixture  of  small  fragments  of  old  vulcanite  and  new  rubber. 
If  the  pieces  are  freshly  filed  all  over,  their  adhesion  with  the  new 
material  will  be  perfect,  and  the  plate  will  be  as  strong  as  though 
wholly  of  new  material. 

There  seems  to  be  a  point  beyond  which,  if  rubber  twice  passes,  it 
becomes  inevitably  brittle;  hence  no  confidence  can  be  placed  in  the 
old  material  of  a  repaired  piece.  Two  flasks  in  the  same  vulcanizer 
cannot  give  the  same  results ;  loss  of  heat  by  radiation  is  greatest  from 
the  cover,  and  the  supply  of  heat  is  from  below ;  hence,  necessarily, 
the  lower  half  of  the  oven  is  hotter  than  the  upper.  Uniformity  of 
texture  can  be  obtained,  therefore,  only  by  vulcanizing  one  piece  at  a 
time.  One  who  is  systematic  in  the  arrangement  of  his  work  will 
separately  vulcanize  the  pieces  of  a  double  set  in  very  nearly  the  same 
time  required  if  both  are  done  at  once ;  for  one  piece  may  be  in  the 
oven,  while  the  other  is  in  preparation  for  it. 

Removal  from  Vulcanizer,  and  Finishing. — Upon  expiration  of  the 
time  determined  upon,  the  flame  is  to  be  at  once  extinguished ;  the  vul- 
canizer may  be  cooled  gradually  as  it  stands,  or  rapidly  by  the  escape 
of  the  steam,  or  by  setting  the  lower  three-fourths  of  the  vulcanizer  in 
cold  water.     The  last  method  of  rapid  cooling  is  preferable  ;^  runniiig  the 


VULCANO-PLASTIC   WORK.  871 

heat  five  minutes  longer  than  when  slow  cooling  is  practiced.  Letting 
off  steam  is  a  very  disagreeable  process,  and  makes  the  plaster  of  the 
flasks  very  hard  to  cut  out.  Flasks  may,  with  perfect  safety,  be  cooled 
by  setting  the  vulcanizer  in  snow  or  pounded  ice,  if  desired ;  but  in  no 
case  should  the  flasks  themselves  be  cooled  by  contact  with  cold  water, 
as  some  might  chance  to  penetrate  to  the  blocks  and  crack  them.  The 
flask  should  be  opened  and  the  piece  removed  from  its  plaster  invest- 
ment, within  two  or  three  hours  after  vulcanizing.  After  that  time 
the  plaster  assumes  a  sand-like,  granular  state,  and  adheres  with  great 
tenacity  to  the  plate,  no  matter  what  separating  varnish  may  be  used. 
Tapping  the  edges  of  the  flask,  after  separation,  will  dislodge  their 
contents  in  mass ;  the  plaster  can  then  be  trimmed  from  the  piece, 
taking  care  that  it  is  perfectly  cold.  The  adherent  plaster  in  the 
dental  half  of  the  flask  can  easily  be  washed  from  the  piece  with  a 
stiff"  brush ;  but  the  model  half  leaves  a  coating  that  clings  very  tena- 
ciously, unless  means  are  taken  to  prevent  it ;  soluble  glass,  a  dilute 
ethereal  solution  of  collodion,  or  a  layer  of  thin  foil,  have  been  already 
mentioned  as  the  proper  preventives. 

The  process  of  finishing  is  more  troublesome  than  in  the  case  of 
gold  work,  unless  great  care  is  used  in  the  formation  of  the  wax  plate. 
Several  sizes  of  round  and  half-round  files  are  necessary  for  finishing 
up  the  edges  and  convex  surfaces;  for  the  concave  surfaces,  scrapers? 
graving  chisels  and  curved  files.  Fig.  668  represents  common  forms 
of  rubber  files. 

Fig.  669  represents  several  sizes  of  a  form  of  scraper  or  finisher, 
suggested  by  Dr.  Kingsley,  with  convex  back  and  thin  edges,  which 
do  not  dull  readily  and  are  easily  sharpened. 

Lathe  burrs  and  file-cut  wheels  will  be  found  very  useful,  if  there  is 
to  be  much  reduction  of  thickness.  Figs.  670  and  671  represent  one 
of  each ;  the  burrs  in  sets  of  four  and  the  wheels  in  sets  of  three.  Suffi- 
cient thickness  must  be  left  in  the  body  of  the  plate  for  strength,  but 
the  edges  should  be  chamfered  off*.  A  pair  of  calipers  (Figs.  629,  630) 
are  required  to  measure  the  thickness  of  the  plate,  if  it  is  to  be  re- 
duced by  files  and  scrapers,  and  the  use  of  this  instrument  will  lessen 
the  danger  of  cutting  through  the  plate.  Some  operators  next  use 
sand  paper  or  emery  cloth ;  others  use  pumice  stone  on  cork  wheels ; 
we  very  decidedly  prefer  Scotch  stone.  The  third  step  is  the  use  of 
rotten  stone  (not  Tripoli,  which  cuts  with  too  keen  a  grit),  either 
on  a  brush  wheel  with  tallow  or  oil,  which  is  the  more  rapid 
process,  or  on  a  stick  of  some  hard  wood,  with  water,  which  is  the 
more  cleanly.  A  little  oxide  of  zinc  on  a  soft  wheel,  or  on  the 
finger,  will  give  a  brilliant  finishing  polish,  but  is  not  essential,  as 
the  rotten  stone  can  be  made  to  polish  very  highly.     After  trying 


872 


MECHANICS. 


Fig.  668. 


Fig.  669. 


Fig.  671. 


VULCANO-PLASTIC  WORK.  873 

the  piece,  and  finding  that  no  part  of  the  edge  requires  alteration, 
a  bright  surface  color  may  be  given  by  placing  the  piece  in  alcohol 
and  exposing  to  the  sun's  rays  for  six  or  twelve  hours.  Some  re- 
gard this  as  an  improvement ;  it  certainly  does  not  injure  the  quality 
of  the  plate,  but  the  original  mahogany  color  of  the  vulcanite  is  in 
much  better  taste  than  the  bright  vermilion  tint  thus  given.  In 
finishing  partial  cases,  it  will  prevent  accident  if,  after  filing  the  edges, 
plaster,  or  modeling  composition,  or  gutta-percha  is  fitted  to  the  pala- 
tine surface  of  the  plate  ;  the  subsequent  operations  can  be  conducted 
more  rapidly  and  with  less  danger,  in  delicately-shaped  pieces.  Vul- 
canite is  softened  by  heat ;  hence  a  piece  is  sometimes  bent  by 
revolving  the  brush-wheel  too  rapidly.  A  piece  that  has  been  in  any 
way  bent  or  warped  may  be  restored  by  heating,  either  in  boiling 
salt  water  or  in  oil,  to  about  250°.  While  soft,  it  may  be  bent 
with  the  fingers ;  but  as  this  guesswork  method  is  hazardous,  it  is 
much  better  to  bind  it  down  upon  a  model,  and  heat  to  the  j)oint 
of  softening. 

By  pouring  plaster  upon  the  palatal  surfaces  of  thin  partial  plates, 
and  allowing  it  to  harden,  the  danger  of  changing  the  shape  when 
polishing  with  a  revolving  wheel  is  avoided.  To  give  a  polished  sur- 
face to  a  vulcanite  plate,  and  dispense  with  the  usual  finishing  up  and 
polishing  process,  the  surface  of  the  wax  may  be  covered  with  tin  foil, 
which  is  lightly,  but  smoothly,  burnished  to  the  surface  of  the  wax. 
To  insure  a  polished  surface  to  the  palatal  surface  of  a  vulcanite  plate 
also,  the  surface  of  the  model  may  be  varnished  with  shellac,  and  then 
covered  with  tin  foil,  evenly  applied  ;  but  a  better  method  is  to  obtain 
a  block-tin  or  other  suitable  metal  die  from  the  plaster  model,  and 
vulcanize  upon  it.  When  tin  foil  is  applied  to  the  surface  of  a  wax 
plate  all  the  wax  may  be  removed  without  injury  to  the  foil,  by  pouring 
boiling  water  upon  it.  By  the  use  of  the  improved  heaters,  to 
vulcanize  rubber,  although  a  longer  time  is  necessary  than  with  the 
common  vulcanizers,  yet  the  strength  and  color  of  rubber  so  manipu- 
lated are  improved.  To  vulcanize  red  rubber  with  these  heaters,  the 
flask  may  be  heated  and  packed  in  the  oven  ;  and  when  this  process 
is  completed  the  machine  is  closed,  and  the  steam  valve  is  then  raised 
to  admit  •the  steam  to  the  packing  chamber.  When  the  heat  has 
been  raised  to  320°  the  case  is  allowed  to  remain  in  the  hot  box,  at 
that  temperature,  for  one  and  a  half  hours. 

To  produce  a  pure  jet-black  rubber  plate,  perfectly  pure  black 
rubber  should  be  used,  and  vulcanized  by  the  dry  process.  The  model 
and  investment  should  be  thoroughly  dried  before  packing  the  black 
rubber,  and  no  steam  be  allowed  to  enter  the  packing  chamber  during 
the  operation.     The  time  required  for  vulcanizing  black  ruboer  by  the 


874  MECHANICS. 

dry  process  is  five  hours,  at  320°  To  construct  a  vulcanite  set  with  a 
celluloid  gum,  see  chapter  on  Celluloid. 

A  modification  of  the  vulcanite  process  was  patented,  in  1868,  by 
Dr.  Stuck.  Briefly  described,  it  is  the  vulcanizing  of  rubber  between 
two  polished  tin-foil  plates,  the  articulating  plate  being  formed  upon 
a  block-tin  model  made  directly  from  the  impression.  The  plate 
comes  out  highly  polished,  provided  the  tin  foil  has  been  carefully 
burnished  into  shape.  On  the  palatine  surface,  this  polish  is  objec- 
tionable ;  hence  we  should  prefer  to  vulcanize  directly  upon  the  block- 
tin  model,  the  granulated  surface  of  which  is  better  for  adhesion. 
The  plate,  thus  made  smaller  than  the  mouth  by  the  shrinkage  of  the 
tin,  would,  in  most  cases,  fit  better ;  the  diflSculty  is  in  removing  the 
finished  plate  from  the  metal  in  case  of  a  deep  arch  or  slight  undercut, 
an  objection,  however,  which  is  now  overcome  by  using  shell  or 
sectional  tin  models.  A  second  peculiarity  of  Dr.  Stuck's  plates  is  their 
elasticity,  compared  with  pieces  as  ordinarily  prepared,  and  vulcanized 
in  the  same  oven.  This,  we  suggest,  is  due  to  the  retention  of  the 
sulphur  by  the  foil  plates  on  either  side.  We  think  these  elastic 
plates  are  usually  made  too  thin,  under  the  idea  that  elasticity,  like 
rigidity,  compensates  for  diminished  thickness.  This  method,  though 
open  to  some  objection,  is  worthy  of  careful  investigation  by  every 
worker  in  vulcanite. 

It  sometimes  happens  that  the  rubber  shrinks  from  the  teeth,  leaving 
a  space  in  which  particles  of  food  and  saliva  collect.  The  cause  of 
such  shrinkage  has  been  ascribed  to  the  fact  that  the  rubber,  in  cooling 
from  a  temperature  of  320°  to  that  of  the  atmosphere,  contracts  more 
than  any  metal,  and  the  plaster  of  the  model  and  investment,  after 
boiling  in  sulphureted  hydrogen  water  for  sixty  minutes,  is  rendered 
very  soft,  and  has  not  strength  sufiicient  to  hold  the  vulcanite  in 
form  while  cooling ;  but,  on  the  contrary,  yielding  to  pressure,  allows 
the  rubber  to  draw  away  from  the  teeth.  It  is  claimed  that  any 
method  which  will  prevent  the  plaster  model  and  investment  from 
becoming  soft,  will  overcome  this  objection. 

Repairing  and  Refitting  Plates. — Vulcanite  work  may  be  repaired 
by  removing  the  broken  tooth  or  block,  cutting  dovetails  in  the  rubber, 
and  then  fitting  the  new  teeth,  arranging  the  wax,  and  vulcnnizing  as 
at  first.  To  describe  this  method  of  repairing  more  in  detail :  if  a 
tooth  or  block  has  been  broken,  the  fractured  parts  should  be  removed, 
and  a  dovetail  or  groove  formed  in  the  base  covering*  the  space  occu- 
pied by  the  tooth  to  be  replaced.  The  tooth  or  block  is  then  fitted  by 
grinding,  and  supported  by  wax,  the  dovetail  being  also  filled  up  rather 
fuller  than  is  necessary  to  restore  the  surface,  in  order  to  allow  for 
finishing.    All  of  the  set,  except  the  portion  of  the  lingual  surface  over 


VULCA NO-PLASTIC  WORK.  875 

the  wax,  is  then  imbedded  in  the  lower  half  of  the  flask,  and  the  plaster 
surface  varnished  and  oiled,  to  prevent  adhesion,  when  the  upper  section 
of  the  flask  is  adjusted  and  filled  with  the  plaster  investment.     When 
the  plaster  has  set,  and  the  two  halves  of  the  flask  are  separated,  all  of 
the  wax  is  removed,  the  piece  heated  up,  and  rubber  packed  into  the 
cavity  around  the  tooth  or  block.     The  sections  of  the  flask  are  then 
heated  and  screwed  together,  and  the  process  of  vulcanizing  completed. 
Another  method  of  repairing  rubber  plates  and  by  which  pressure  is 
avoided,  is  to  first  cleanse  the  piece  thoroughly,  and  to  coat  the  inner 
surface  with  a  little  oil,  to  prevent  the  plaster  which  is  poured  upon 
this  surface  in  order  to  form  a  new  model  from  adhering.     When  the 
plate  is  separated  from  the  model,  dovetails  are  cut  into  the  plate,  and 
it  is  returned  to  the  model,  and  the  teeth  adjusted  by  grinding,  after 
which  the  surface  under  them  is  coated  with  the  rubber  solder,  or 
liquid  rubber,  as  is  also  such  parts  of  the  teeth  and  pins  that  are  to 
come  in  contact  with  the  rubber.     The  teeth    being  replaced,  warm 
rubber  is  packed  under  them  and  into  the  dovetails,  and  the  case  is 
then  invested  in  one  mass  of  plaster,  no  flasks  being  used,  and  vulcan- 
ized in  the  ordinary  manner.     Where  the  plate  is  cracked,  or  broken 
into  two  pieces,  the  parts  should  be  carefully  adjusted  and  secured  in 
place   by  either  wax  or  ligatures,  and  covered   with  plaster  on  its 
inner  surface,  so  as  to  form  a  model.     The  plate  is  removed  from  the 
plaster  when  it  has  set,  and  a  groove  cut  out  the  entire  length  of  the 
crack  or  fracture,  on  either  side  of  which  dovetails  are  formed.    When 
the  pieces  are  returned  to  the  model,  the  case  is  placed  in   the  lower 
half  of  the  flask  and  invested  with  plaster,  all  portions  of  the  plate 
being  covered  .except  where  the  new  rubber  is  to  be  packed.     The 
rubber  solder  is  then  applied  to  the  prepared  surface,  and  the  rubber 
packed  firmly  into  the  groove  and  dovetails.     The  upper  half  of  the 
flask  is  then  adjusted  and  the  investment  completed,  when  the  case  is 
ready  for  vulcanizing.     Instead  of  cutting  dovetails,  which  are  often 
disfiguring  and  sometimes  impracticable,  a  liquid  preparation  may  be 
used,  known  as  Rubber  Solder.   The  surface  of  the  old  plate  should  be 
brushed  over  with  it  just  before  packing.     The  adhesion  is  so  perfect 
that   the   plate  will    break  through  old  or  new  rubber  sooner  than 
separate.     Before  cutting  out  the  old  rubber,  the  part  of  the  plate 
under  the  broken  teeth  should  be  filled  with  plaster  and  then  removed, 
so  as  to  preserve  the  shape  of  the  ridge ;  in  case  the  process  of  repair 
requires  that  the  plate  shall  be  cut  entirely  through  at  this  point,  it  is 
to  be  replaced  before  applying  the  wax.     The  second  heating  darkens 
the  old  rubber  and  makes  it  more  brittle  ;  full  cases  may  admit  of 
one,  possibly  two,  such  heatings.     Partial  cases  should  be  repaired  by 
replacing  the  entire  plate  with  new  rubber ;  although  many  repair  as 


876  MECHANICS. 

in  full  pieces.  We  decidedly  prefer,  in  both  full  and  partial  cases, 
the  entire  replacement  of  the  rubber.  In  doing  this,  there  are  various 
ways  of  securing  the  correct  relation  of  the  teeth  to  the  new  model. 
To  replace  a  broken  partial  or  full  plate,  the  teeth  being  uninjured, 
attach  the  broken  parts  firmly,  by  resinous  cement,  on  the  lingual 
surface ;  soap  the  rubber,  or  very  slightly  oil  it,  and  make  a  new 
model  ;  then  surround  it  with  a  plaster  rim,  as  explained  on  page  768, 
coming  fully  to  the  edges  of  the  teeth.  Remove  the  resinous  cement 
from  the  lingual  side  of  the  plate,  and  take  a  plaster  copy  of  this  surface 
and  of  the  inside  of  the  teeth  ;  being  careful,  in  partial  cases,  to  slope 
the  plaster  so  that  it  may  be  readily  drawn.  The  plaster  now  envel- 
oping the  piece  is  in  three  or  in  four  parts  ;  remove  the  plaster  from 
the  lingual  surface;  remove  the  rim  in  one  or  in  two  pieces;  then 
carefully  remove  the  plate  from  the  model.  Soften  the  rubber  plate 
and  remove  the  teeth  ;  replace  the  plaster  rim  around  the  model  and 
set  the  teeth  or  blocks  in  position,  pressing  a  little  wax  under  each,  to 
keep  it  in  place.  Now  set  model,  rim  and  teeth  in  the  half-flask,  first 
soaking  in  water,  to  prevent  too  quick  setting  of  the  batter.  Soap,  or 
cover  with  foil,  the  plaster  surface  ;  then  saturate  and  put  in  place 
the  remaining  lingual  piece  of  plaster  ;  set  the  other  half- flask,  and 
pour  the  remaining  half-matrix.  Separate  flask,  pick  out  the  pieces 
of  wax  ;  the  case  is  then  ready  for  packing  and  vulcanizing.  By  this 
process  the  new  plate  has  the  exact  shape  of  the  old  one,  and  there  is 
no  necessity  for  moulding  a  new  wax  plate.  If  the  plate  is  of  such 
form  as  to  endanger  the  model  in  detaching,  soften  it  by  cautious 
use  of  the  blowpipe  flame. 

If  a  new  teeth  or  block  is  required,  let  this  be  first  fitted,  and  wax 
properly  shaped  around  it;  then  proceed  as  above.  But  if  some  modi- 
fication in  the  shape  or  thickness  of  the  plate  is  required,  do  not  fill 
the  lingual  surface  with  plaster  ;  but,  after  making  model  and  rim, 
remove  plate,  reset  teeth,  adjust  a  new  wax  plate,  and  then  proceed  as 
in  a  new  piece.  If  the  vulcanite  rim  outside  and  above  the  teeth 
needs  modification,  the  plaster  rim  must  be  removed  and  wax  placed 
there  also,  as  in  a  new  piece. 

Dr.  George  B.  Snow,  in  an  excellent  article  on  "  Repairing  Vulcanite 
Plates,"  gives  the  following  suggestions : — 

"  It  is  not  unusual  to  see  vulcanite  plates  which  have  been  cracked 
or  broken,  and  repaired  by  what  may  be  termed  the  "  hole  and  plaster" 
system.  Holes  are  drilled  through  the  plate,  along  the  edges  of  the 
crack,  and  a  new  thickness  of  rubber  superimposed  upon  a  mass  which 
possibly  is  already  too  thick  for  comfort  or  convenience ;  the  old  crack 
still  remaining  as  a  weak  point  to  occasion  further  breakage.  No 
advantage  was  taken  of  any  possibility  of  union  between  the  old  and 


VULCANO-PLASTIC  WORK.  877 

new  material,  the  dentist  having  been  obviously  ignorant  of  the  fact 
that  perfect  union  can  be  obtained  in  such  cases  if  the  surfaces  oi, 
contact  are  freshly  cut,  absolutely  clean,  and  properly  roughened. 

"  The  great  point  to  be  remembered  in  repairing  or  making  any 
addition  to  a  vulcanite  plate  is,  that  the  new  and  old  material  will 
unite  perfectly,  and  with  such  firm  adhesion  that  the  plate  will  be 
practically  as  good  as  new,  if  the  surfaces  of  the  old  plate  where  union 
with  the  new  material  is  desired  are  freshly  filed,  absolutely  clean, 
properly  roughened,  and  of  sufficient  area.  To  insure  these  results, 
wax  should  not  be  melted  upon  the  surfaces  of  union  in  waxing  up, 
and  removal  of  the  wax  from  the  mould  should  be  accomplished  by 
means  of  instruments,  and  not  by  hot  water,  unless,  possibly,  for  the 
removal  of  very  small  particles  which  cannot  otherwise  be  got  rid  of. 
Any  amount  of  the  old  material  desired  may  be  cut  away,  and  its 
place  supplied  by  new ;  and  thus  any  change  wished  may  be  effected. 
In  case  of  breakage  or  cracking,  the  plate  should  be  cut  away  so  that 
the  old  defects  will  be  wholly  obliterated  and  new  material  supplied. 

"  As  a  first  instance,  suppose  a  partial  lower  plate,  supplying  the 
loss  of  the  bicuspids  and  molars  on  both  sides  of  the  mouth,  to  be 
broken  through  the  bar  which  extends  from  one  side  of  the  mouth  to 
the  other  behind  the  incisors.  The  fracture  is  generally  a  clean  one, 
resembling  that  of  glass  or  porcelain,  and  the  two  pieces  may  be 
brought  into  apposition  with  certainty.  The  dentist  holding  the  parts 
together  in  exactly  the  right  position,  the  assistant  covers  the  lingual 
side  of  the  plate  at  the  point  of  fracture  with  a  few  drops  of  hot  shellac 
from  a  shellac  stick.  A  little  cold  water  follows,  and  the  two  parts 
of  the  plate  are  firmly  cemented  together.  A  brace  is  now  extended 
across  from  the  molars  on  one  side  to  those  on  the  other,  by  laying 
a  burnt  match  on  the  grinding  surfaces  of  the  respective  teeth,  and 
fastening  both  ends  with  a  few  drops  of  hot  wax.  By  this  means, 
sufficient  strength  is  obtained  to  allow  of  the  plate  being  safely  handled. 
A  piece  of  paper  or  sheet  wax  is  cut  to  fit  and  reach  across  the  lingual 
space  at  the  lower  edge  of  the  plate,  and  fastened  therein  with  wax,  a 
coat  of  shellac  varnish  is  applied  to  the  paper,  the  surface  lathered 
with  soap-suds,  and  rinsed,  and  a  model  run  in  the  same  manner  as  in 
filling  an  impression. 

"  After  this  has  hardened,  the  plate  is  removed  from  the  model, 
which  is  then  given  a  coating  of  liquid  silex.  This  is  always  preferably 
done  in  repairing  plates,  at  the  time  when  the  plate  is  first  removed 
from  the  model.  The  bar  may  be  now  wholly  cut  away,  close  to  the 
body  of  the  plate  on  either  side,  by  a  jeweler's  saw ;  the  cut  being 
made  diagonally,  so  as  to  make  what  is  termed  a  "  scarf"  joint.  The 
surfaces  should  be  further  roughened  by  making  a  series  of  shallow 


8/8  MECHANICS. 

parallel  cuts  across  them  with  the  saw,  a  thick  separating  file,  or  a 
thin  wheel  engine  burr.  The  parts  of  the  plate  are  placed  upon  the 
model,  waxed  up,  and  flasked ;  the  model  and  buccal  surfaces  of  the 
teeth  being  covered  with  plaster,  and  the  parting  made  so  that  the 
plate  will  be  retained  upon  the  model,  while  the  pieces  of  the  bar  can 
be  readily  removed.  After  the  flask  is  opened,  the  pieces  are  re- 
moved, the  usual  gateways  cut,  and  the  packing,  vulcanizing  and 
finishing  done,  as  usual. 

"  In  the  case  of  an  entire  lower  set  broken  through  the  centre,  it 
will  be  seen  that  the  same  directions  will  apply,  excepting  as  to  the 
amount  of  rubber  to  be  cut  away.  A  free  cut  should  be  made  on  the 
lingual  side,  extending  through  under  the  teeth,  to  and  including  the 
labial  band ;  so  that  the  broken  surfaces  will  be  entirely  obliterated 
and  at  least  one-eighth  inch  in  width  of  new  rubber  supplied  between 
the  cut  surfaces.  An  engine  burr  will  do  much  of  this  work  nicely, 
and  a  wheel  burr  is  very  convenient  for  the  purpose  of  scoring  the 
surface.  The  making  a  model,  flasking  and  packing  will  be  done 
as  before. 

"  If  one  of  the  incisor  blocks  be  broken,  and  needs  replacement,  a 
new  one  can  be  fitted  after  the  model  is  obtained,  and  the  remaining 
steps  of  the  process  followed  as  has  been  described. 

"  Upper  plates  are  sometimes  cracked  in  the  centre,  the  crack 
extending  from  under  and  between  the  incisor  teeth  backward  over 
the  palate.  This  often  happens  from  the  amount  of  rubber  just  behind 
the  incisors  being  insufficient.  It  is  not  unusual  to  see  it  cut  away 
at  this  point,  so  that  the  pins  are  almost  or  quite  exposed  ;  the  plate 
having  its  usual  thickness  at  a  very  short  distance  behind  the  teeth. 
A  much  larger  amount  of  material  will  be  tolerated  here  than  is 
usually  employed,  and  often  with  benefit,  not  only  to  the  strength  of 
the  plate,  but  to  the  articulation  of  the  wearer.  The  curve  of  the 
surface  of  the  plate  should  be  made  to  resemble  that  of  the  palate 
before  the  removal  of  the  teeth,  and  it  will  be  found  that  the  extra 
thickness  may  extend  for  half  an  inch  behind  the  teeth  without  annoy- 
ance to  the  patient. 

"  A  proper  curvature  to  the  surface  of  the  plate,  just  behind  the 
incisors,  will  do  much  to  prevent  the  disagreeable  whistling  in  making 
the  s  sound,  and  will  assist  in  giving  the  correct  enunciation  to  sh,  zh, 
and  other  Unguals. 

"  If  the  cracked  plate  fits  a  flat  mouth,  a  model  can  often  be  drawn 
from  it  as  it  is;  but  if  the  arch  is  high,  and  the  gums  projecting,  it  is 
better,  after  thoroughly  cleansing  and  drying  the  plate,  to  flnish  the 
cracking  by  breaking  the  plate  entirely  in  two.  The  two  halves  may 
now  be  fastened  together  by  dropping  shellac  upon  the  lingual  side, 


VULCANO-PLASTIC   WORK.  879 

and  a  inoclel  secured,  from  which  either  half  of  the  plate  can  be  easily- 
removed.  The  whole  palatal  portion  of  the  plate  can  then  be  removed 
by  a  saw  cut,  leaving  only  a  narrow  margin  on  the  lingual  surface 
inside  the  teeth.  The  remainder  of  the  surfaces  of  fracture  are  cut 
away  as  directed  in  case  of  the  lower  plate,  the  new  surfaces  roughened, 
the  pieces  of  the  old  plate  replaced  upon  the  model  (which  has  received 
its  coating  of  liquid  silex),  waxed  up,  flasked,  packed  and  vulcanized, 
the  teeth  being  retained  upon  the  model  as  before  described.  The 
plate,  when  finished,  will  show  the  old  rim  and  a  margin  of  the  old 
rubber  inside  the  teeth. 

"  It  is  sometimes  desirable  to  change  the  substance  of  the  plate 
entirely,  as  in  case  of  supposed  mercurial  poisoning  by  red  rubber ;  or 
at  least  to  put  what  red  rubber  there  may  be  about  the  plate  entirely 
out  of  sight,  and  to  reduce  its  quantity  to  a  minimum.  If  this  is  to  be 
done  to  the  plate  last  under  consideration,  it  should  be  prepared  for 
flasking  as  described,  excepting  that  the  labial  band  should  be  cut 
away,  and  everything  arranged  so  that  the  plate  can  be  separated 
from  the  model  when  flasked.  The  parts  cut  away  should,  of  course, 
be  replaced  by  wax.  The  case  is  now  set  in  the  flask  so  as  to  leave 
the  parting  at  the  upper  edges  of  the  gums.  The  plaster  is  varnished 
and  oiled,  and  more  plaster  built  on  against  the  labial  sides  of  the 
teeth,  extending  from  their  cutting  edges  to  the  edge  of  the  flask,  and 
again  varnished  and  oiled,  so  that  the  appearance  will  now  be  pre- 
cisely similar  to  a  plate  flasked  so  as  to  be  retained  upon  the  model. 
The  ring  of  the  flask  is  now  put  in  place  and  filled,  and  the  plaster 
allowed  to  harden. 

"  When  the  flask  is  separated,  the  teeth  will  be  found  in  its  ring 
section.  A  few  blows  of  the  hammer  will  dislodge  them,  with  the 
piece  of  plaster  built  against  their  labial  surfaces.  This  is  carefully 
broken  away,  in  two  pieces  if  possible,  which  are  preserved,  and  the 
teeth  and  rubber  encasing  them  is  left.  The  rubber  is  now  filed  away 
as  much  as  is  practicable,  leaving  none  of  the  old  rubber  in  sight,  and 
removing  enough  from  the  palatal  surface  to  make  a  new  fit  to  the 
model.  The  teeth  and  plaster  are  replaced  in  the  flask,  and  the  case 
is  ready  for  packing  and  vulcanizing,  and,  when  finished,  none  of  the 
old  rubber  will  be  seen,  and  the  plate  will  be  practically  as  good  as 
though  the  teeth  had  been  removed  from  the  old  plate  and  reset. 

"It  is  sometimes  difiicult  to  prevent  the  rubber  from  showing  at  the 
joint  between  the  incisors  ;  great  care  should  be  exercised  in  bringing 
the  sections  together  properly  and  in  holding  them  in  position  while 
flasking.  If  there  is  room,  a  small  wisp  of  loose  cotton,  not  larger 
than  a  thread,  may  be  tucked  into  the  joint  on  its  palatal  side,  the 
edges  of  the  blocks  being  beveled  to  admit  of  this  being  done. 


880  MECHANICS. 

"  It  is  evident  that  the  change  from  red  to  black  rubber  just  described 
can  be  made  with  a  whole  plate  or  a  broken  one  indifferently.  If  a 
change  of  articulation  and  a  new  fit  to  the  mouth  is  also  desired,  on 
account  of  shrinkage  of  the  gums,  the  plate  should  be  prepared  so  as 
to  draw  from  the  model,  and  a  few  small  pieces  of  wax  put  in  the 
palatal  side  to  bear  upon  the  alveolar  ridge,  and  give  the  right  articu- 
lation by  trial  in  the  mouth,  the  centre  of  the  plate  being  cut  away  to 
facilitate  the  fitting  of  the  plate  to  the  model.  A  fresh  model  of  the 
mouth  being  secured  from  an  impression,  the  plate  is  waxed  on  to  it, 
the  case  is  flasked  with  a  false  piece  of  plaster  built  against  the  labial 
sides  of  the  teeth,  as  has  been  before  described,  and  the  plate  after- 
ward removed  and  cut  away  as  much  as  desired ;  a  considerable 
amount  being  always  taken  from  its  palatal  surface. 

"  This  process  does  all  and  more  than  is  specified  in  the  Hyatt  patent, 
as  it  not  only  gives  a  new  fit,  but  allows  the  material  of  the  plate  to  be 
substantially  changed.  Holes  and  dovetails,  it  will  be  seen,  are  wholly 
unnecessary,  and  the  fine  serrated  edge  left  by  cross-cutting  the  sur- 
faces of  union  will  be  found  an  excellent  guide  in  sci'aping  the  plate 
to  avoid  overlaps.  The  use  of  shellac  as  a  cement  is  strongly  advised 
in  repairing,  as  it  is  rigid  and  brittle  when  cold,  and  the  broken  parts, 
if  once  properly  brought  together,  cannot  get  out  of  adjustment  without 
at  once  attracting  attention  by  the  breakage  of  the  cement.  Wax  does 
not  answer  the  purpose  nearly  so  well. 

"  The  amount  of  shrinkage  in  vulcanite,  from  cooling  after  vulcani- 
zation, is  not  so  generally  noticed  and  provided  for  as  it  should  be. 
Plates  composed  of  single  teeth  do  not  give  trouble  from  this  cause, 
but  full  plates,  on  which  sections  are  mounted,  are  often  very  vexa- 
tious to  the  dentist,  from  the  change  of  shape  they  undergo  from 
shrinkage. 

"  The  reason  of  this  is,  that  the  ends  of  the  sections  abutting  form 
an  arch  of  porcelain,  which  expands  or  contracts  but  slightly  from 
changes  of  temperature.  The  rib  of  vulcanite  immediately  inside 
this  arch,  and  in  which  the  pins  are  embedded,  forms  a  second  arch 
closely  attached  by  the  pins  to  the  first  one.  The  plate  is  moulded  to 
the  model,  and  hardened  at  a  temperature  of  about  320°,  and  is  after- 
ward placed  in  the  mouth,  where  the  temperature  is  in  the  neighbor- 
hood of  90°.  Under  these  circumstances  the  contraction  of  the  rubber 
which  ensues  has  the  eifect  of  lessening  the  radius  of  the  arch,  drawing 
the  heels  of  the  plate  together,  thus  rendering  it  a  little  too  narrow 
to  fit  the  mouth  accurately.  This  has  the  further  efiect  of  elevating 
the  palatal  portion  of  the  plate,  which,  when  tried  in  the  mouth,  will 
usually  be  found  to  rock  slightly ;  often  so  much  as  to  interfere  with 
its  fitting. 


VULC  A  NO-PLASTIC   WORK.  881 

"  If  the  plate  has  been  made  upon  a  model  taken  from  the  mouth, 
the  difficulty  is  overcome  by  warming  the  back  part  of  its  palatal 
portion,  pressing  it  down  slightly,  and  cooling  it  while  the  pressure  is 
continued ;  the  narrowing  of  the  plate  being  too  small  in  amount  to 
be  of  itself  objectionable. 

"This  change  can  be  accomplished  with  more  certainty  by  makino-  a 
small  plaster  cast  of  the  palatal  portion  of  the  plate,  placing  upon  the 
part  where  the  change  is  desired  a  small  piece  of  folded  paper,  folded 
so  as  to  present  a  thick  centre,  and  forcing  the  plate  down  upon  it 
after  its  palatal  portion  has  been  warmed. 

"  The  shrinkage  here  alluded  to  becomes  a  more  serious  matter  when 
the  plate  is  re-vulcanized,  in  the  course  of  repairing  it.  It  is  flasked 
when  the  change  in  form  by  its  shrinkage  has  already  once  manifested 
itself,  and  again  heated  to  320°  ;  and  in  cooling  a  second  shrinkage 
takes  place,  it  becomes  still  narrower,  and  its  fit,  already  defective,  is 
made  perceptibly  worse.  It  now  often  becomes  a  matter  of  necessity 
to  bring  it  back  to  its  proper  shape  before  it  can  be  worn  with  comfort. 
To  provide  for  this,  a  small  dot  should  be  made  with  a  pointed  instru- 
ment on  each  side  of  the  plate,  immediately  behind  the  molars,  and  a 
pair  of  dividers  set  to  the  distance  between  these  points.  After  vul- 
canization, the  dividers  can  be  applied  to  the  marks,  and  they  will 
indicate  the  amount  of  shrinkage  the  plate  has  experienced.  Let  the 
plate  now  be  warmed  just  behind  the  incisors,  and  in  the  mesial  line, 
by  repeated  short  pufts  of  a  blowpipe  flame.  This  must  be  done  care- 
fully, and  the  heat  not  allowed  to  extend  over  an  area  much  exceeding 
half  an  inch  in  diameter.  When  the  rubber  is  sufficiently  softened, 
the  plate  should  be  taken  by  the  heels,  a  pull  made  upon  it  sufficiently 
forcible  to  expand  the  arch,  and  a  stream  of  cold  water  applied.  The 
dividers  will  at  once  show  if  the  change  made  is  sufficient. 

"  When  the  plate  is  now  tried  in  the  mouth,  it  may  be  that  the  back 
edge  will  not  touch  the  roof,  and  air  will  be  admitted  under  the  plate; 
in  which  case  the  back  edge  should  be  warmed  and  forced  up  to  its 
proper  position. 

"  The  same  remarks  apply  to  full  lower  plates  as  well,  which  often 
are  found  to  have  lost  their  fit  in  a  measure,  after  having  been  re- 
vulcanized.  The  process  above  detailed  will  suffice  to  restore  them  to 
their  former  fit,  and  render  them  again  comfortable  to  the  wearer." 

If  the  teeth  are  to  be  reset,  because  of  change,  from  absorption,  or 
because  of  some  inaccuracy  in  the  fit  of  the  plate,  it  will  perhaps  be 
best,  in  most  cases,  to  proceed  just  as  for  a  new  piece,  grinding  the 
joints  again  for  any  change  of  arrangement.  Sometimes  re-jointing 
the  blocks  may  be  saved  by  bedding  their  cutting  edges  and  cusps  in 
a  gutta-percha  rim,  before  detaching  from  the  plate  ;  this  will  permit 
56 


882  MECHANICS. 

their  adjustment  to  the  new  wax  plate  in  a  continuous  arch.  Some- 
times the  old  plate  may  with  advantage  be  used  as  an  impression  cup, 
by  roughening  the  rubber,  and  using  a  very  thin  layer  of  wax  or  plas- 
ter, whichever  bests  suits  the  case.  In  making  the  model,  extend  it 
backward,  as  before  described  under  Articulation  of  Plastic  Work. 
Before  removing  the  piece  complete  the  articulator,  making  the  plaster 
cover  the  edges  and  cro^^Tls  of  the  teeth  one-eighth  of  an  inch.  By  setting 
the  blocks,  when  removed  from  the  old  plate,  into  their  depressions  on 
the  articulator,  the  exact  relations  of  blocks  to  the  model  is  preserved ; 
also,  if  the  plaster  of  the  impression  is  made  accidentally  too  thick,  the 
articulator  may  be  slightly  closed.  The  wax  plate  is  arranged  first  on 
the  outside ;  the  half-articulator  is  then  removed,  and  the  inner  part 
of  the  plate  shaped.  The  articulating  portion  is  theh'cut  off,  the  model 
set  in  the  flask,  and  the  process  completed  in  the  usual  manner. 

Gold,  platina,  or  aluminum  plates  may  also  be  re-fitted  to  suit  a 
mouth  cTianged  by  absorption.  Perforate  the  plate  with  holes  about 
size  jS'o.  22  (Fig.  512),  countersunk  on  lingual  side,  regularly  arranged 
and  about  half  an  inch  apart.  Fill  the  lingual  surface  between  teeth 
with  plaster ;  remove  this  when  hard  and  make  countersinks  in  it, 
opposite  each  hole  in  the  plate.  Set  the  plate  on  model  and  fasten  it 
with  wax  around  the  entire  edge  ;  then  place  in  half  flask,  as  usual. 
Replace  the  countersunk  pieces  of  plaster  and  pour  second  half  matrix  : 
this  piece  of  plaster  and  the  wax  around  the  edge  prevent  the  batter 
of  the  matrix  from  getting  between  plate  and  model.  Separate  flask, 
cut  vents,  put  in  a  sheet  of  prepared  rubber  of  proper  size,  press  ma- 
trix together  and  vulcanize.  The  impression  may  be  taken  in  the 
usual  cups  or  in  the  plate  itself,  and  with  either  plaster  or  wax,  as  the 
case  may  require ;  if  taken  in  the  plate,  cleanse  this  carefully  after 
making  the  model.  The  adhesion  of  the  rubber  may  be  increased  by 
cutting  the  palatine  surface  of  the  metallic  plate  with  a  sharp  graver  ; 
it  should  be  carefully  cleansed  just  before  packing  the  rubber. 

Dr.  Richardson  gives  the  following  method  of  refitting  gold  or 
vulcanite  plates  with  a  new  vulcanite  lining  :  "  Perforate  the  palatal 
portion  of  the  plate  with  from  eight  to  twelve  holes,  at  different  points, 
and  also  the  extreme  borders,  from  heel  to  heel  of  the  plate,  at 
intervals  of  one-eighth  to  half  an  inch  apart,  and  near  the  edges. 
These  holes  may' be  enlarged  to  the  dimensions  of  a  medium-sized 
knitting  needle;  or  if  the  piece  is  of  vulcanite,  to  twice  or  three  times 
that  size.  On  the  lingual  and  buccal  surfaces  the  holes  are  well 
countersunk  with  a  burr  drill.  The  plate  is  employed  as  a  cup  or 
holder  to  take  an  impression  of  the  mouth  in  plaster,  being  pressed  up 
closely  to  the  parts.  The  plaster  forced  through  the  holes,  and  filling 
the  countersinks  on  the  opposite  side  of  the  plate,  will  serve  to  bind 


VULCANO-PLASTIC   WORK.  883 

the  plaster  to  the  plate,  and  prevent  the  two  from  separating  as  they 
are  detached  from  the  mouth.  When  removed,  the  plaster  impression 
lining  the  plate  is  trimmed  even  with  the  borders  of  the  latter,  and 
varnished  and  oiled.  The  lower  section  of  the  vulcanizing  flask  is  now 
filled  with  a  batter  of  plaster  on  a  level  with  its  upper  surface,  and 
the  impression,  filled  with  the  same,  is  turned  over  and  placed  in  the 
centre  of  the  flask,  with  the  edges  of  the  plate  touching  the  surface  of 
the  plaster.  The  plate  and  adhering  plaster  are  now  carefully  sepa- 
rated from  the  model.  After  cutting  out  the  plaster  from  the  holes 
and  countersinks  in  the  plate,  the  plaster  forming  the  impression  is 
detached  from  the  plate,  and  the  holes  and  countersinks  filled  with 
wax.  The  plate  is  then  readjusted  over  the  model,  and  (the  surround- 
ing surface  of  the  plaster  in  the  flask  having  been  varnished  and  oiled) 
plaster  is  poured  in  upon  the  upper  surface  of  the  plate  and  teeth, 
filling  the  upper  ring.  When  the  plaster  is  sufiiciently  hard,  the  two 
sections  of  the  flask  are  separated,  and  grooves  formed,  running  out 
from  the  matrix  to  the  margins  of  the  flask.  A  sufiScient  quantity  of 
vulcanizable  rubber  is  now  either  placed  upon  the  model,  or  jjacked 
in  upon  the  palatal  surface  of  the  plate;  before  doing  which,  however, 
the  wax  filling  the  holes  and  countersinks  in  the  plate  (and  which 
was  placed  there  to  prevent  portions  of  plaster  last  poured,  in  forming 
the  matrix,  from  filling  them  up)  should  be  worked  out  with  a  small 
instrument.  The  whole  being  sufficiently  heated,  the  two  sections  of 
the  flask  are  forced  together,  expelling  redundant  material.  The  piece 
is  then  vulcanized." 

The  late  Dr.  Wildman  suggested  the  following  method  of  forming  a 
new  plate,  without  changing  the  articulation  of  the  teeth :  "  Roughen 
the  palatal  surface  of  the  rubber  plate,  to  cause  the  plaster  to  adhere 
to  it ;  then  use  it  as  an  impression  cup  to  take  a  plaster  impression, 
being  careful,  when  it  is  in  the  mouth,  to  preserve  the  articulation.  In 
this  impression  cast  the  model ;  trim  and  cut  conical  holes  at  several 
points  in  its  outer  face.  Now,  before  separating  the  impression  from 
the  model,  make  a  cast  of  the  face  of  the  teeth,  in  two  or  three  perpen- 
dicular sections,  extending  to  the  base  of  the  model,  using  a  solution  of 
soap  or  other  parting  substance  on  the  plaster  model.  Remove  this 
mould  of  the  face  of  the  teeth,  which  indicates  their  true  position 
relative  to  the  model.  Then  take  the  impression  from  the  model.  By 
the  aid  of  heat  sufficient  to  soften  the  rubber,  remove  the  teeth  from 
it.  Next  make  a  model  plate  with  prepared  gutta-percha,  '  wax  and 
paraffine  (or  modeling  composition).'  Now  secure  the  sections  of  the 
mould  of  the  face  of  the  teeth  to  the  model  (their  place  will  be  indi- 
cated by  the  conical  holes  or  keys)  ;  adjust  the  teeth  in  their  proper 
positions  in  the  plaster  mould  of  them,  and  build  up  with  wax  to  the 


884  MECHANICS. 

proper  form  of  the  model  set.  This  being  done,  test  its  accuracy  of 
contour  and  articulation  by  placing  it  in  the  raouth.  Then,  using  the 
model,  proceed  as  for  making  a  new  set."  The  method  just  described 
requires  the  presence  of  the  patient ;  but  cases  occur  where  this  is 
not  possible,  and  owing  to  accident  a  new  plate  is  necessary,  and  the 
articulation  must  be  preserved.  Take  a  case,  for  an  example,  where  the 
plate  is  so  fractured  that  it  cannot  be  repaired,  and  yet  is  capable  of 
being  temporarily  adjusted,  by  means  of  hot  wax  dropped  from  a  spatula. 
When  this  is  done,  the  palatal  surface  of  the  plate  is  coated  lightly 
with  oil  and  plaster  batter  poured  into  it  to  form  a  model.  Then  trim 
the  edges  of  the  plate,  and  sides  of  the  model,  and  form  holes  of  a 
conical  shape  to  act  as  keys  for  the  mould  which  is  made  in  sections 
of  the  outer  face  of  the  teeth.  When  this  mould  has  become  hard,  the 
sections  of  it  are  removed,  as  well  as  the  plate  from  the  plaster  model. 
Undercuts  may  prevent  the  ready  removal  of  the  old  vulcanite  plate, 
and  in  such  a  case,  to  prevent  injury  to  the  model,  the  old  plate  should 
be  softened  by  heat.  The  subsequent  manipulation  is  the  same  as  in 
the  previous  method.  When  the  plate  is  broken  in  half,  a  rubber 
plate  may  be  repaired  by  a  method  suggested  by  Dr.  Gilbert :  "  Re- 
move the  denture,  and,  with  a  fine  Swiss  saw,  cut  away  the  palatal 
portion  of  the  plate  to  within  about  an  eighth  of  an  inch  of  the  inner 
surface  of  the  teeth.  In  this  remaining  portion  cut  dovetails,  to  retain 
the  new  rubber,  and  also  form  an  undercut  channel  in  the  portion 
which  fits  over  the  alveolar  ridge  in  the  line  of  the  break,  as  far  as  the 
edge  of  the  rim  ;  secure  the  parts  to  the  model  with  wax.  The  cut-out 
palatal  portion  may  then  be  laid  back  in  place,  to  aid  in  waxing  up 
that  part.  Invest  in  the  flask,  covering  the  labial  and  grinding  por- 
tions of  the  teeth,  as  in  other  repair  work.  After  separating,  remove 
the  part  desired  to  be  replaced  with  new  material ;  pack  and  vulcanize 
as  usual." 

Partial  pieces  can  usually  be  retained  by  stays  and  the  fit  of  the 
plate.  If  clasps  are  called  for,  these  may  be  made  of  rubber  alone, 
if  the  clasps  are  short  and  the  rubber  elastic;  or  of  rubber  strength- 
ened by  a  gold  wire,  which  is  to  be  curved 
Fig.  672.  around  the  clasp  tooth  just  before  packing. 

xg^^^__^^,^_^  /^'^''^^^  A  gold  clasp  may  also  be  fitted  and  re- 
'^y'^^^^^  '      ^4    tained  in  the  rubber,  either  by  a  project- 

■^    ^^^^y^         '^     \^y  ing  slip  of  the  same  metal  or  by  soldering 

'**=^«=^  '^=^^^  into  it  one  or  two  platinum  pins.    Fig.  672, 

taken  from  Prof.   Wildman's  monograph, 

represents  these  two  forms  of  clasp ;  but  in  cases  requiring  clasps,  we 

very  decidedly  prefer  a  gold  plate.     The  larger  size  of  vulcanite  plates 

necessary  for  strength  will,  usually,  secure  adhesion,  with  the  help  of 


VULO A  NO-PLASTIC   WORK. 


885 


stays  or  half  clasps;  in  none  of  these  cases  do  we  consider  the  vacuum 
cavity  of  any  service. 

Combination  of  Vulcanite  with  Metallic  Plates. — Blocks  or  gum  teeth 
may  be  secured  to  gold  plate  by  vulcanite  instead  of  by  soldering. 
Blocks  having  a  porcelain  gum  on  the  inside,  finished  to  the  plate  and 
having  a  hole  in  the  base  opposite  each  tooth,  present  a  very  handsome 
appearance  when  attached  to  gold  plate  by  vulcanite,  and  may  be 
made  very  secure.  The  hole  should  be  of  good  size  (from  Nos.  12  to 
15,  Fig.  512),  but  must  not  come  so  near  the  translucent  front  of  the 
tooth  as  to  permit  the  color  of  the  rubber  to  darken  it.  In  this  and 
the  subsequent  modes  of  attachment,  the  swaging,  articulation  and 
grinding  of  blocks  is  done  as  usual,  except  that  there  is  less  necessity 
for  close  fitting  to  the  plate  than  in  case  of  soldered  work.  The  tem- 
porary plaster  rim,  elsewhere  described,  must  in  all  cases  be  used,  so 
as  to  permit  removal  and  correct  replacement  of  teeth.  In  case  of  the 
blocks  just  described,  press  each  block  into  place  over  a  thin  layer  of 


Fig.  673. 


Fig.  674. 


wax  on  the  gold  plate.  The  wax  projection  made  by  each  hole  shows 
where  to  drill  the  plate  for  the  pins  ;  then  remove  plate,  drill  holes  and 
solder  roughened  or  headed  pins  into  the  plate,  opposite  each  hole ; 
fasten  the  blocks  temporarily  with  wax,  then  invest  in  the  vulcanizing 
flask,  so  that  on  separating  the  matrix,  the  plate  shall  come  away  in 
one  half,  the  teeth  in  the  other.  Fill  the  holes  with  rubber,  and 
place  a  strip  over  the  base  of  the  blocks ;  warm  and  replace  the 
two  halves  of  the  matrix,  and  vulcanize.  Vulcanite  blocks,  such 
as  those  in  Figs.  673  and  674,  may  be  very  firmly  attached  to  metal 
plates  by  some  one  of  the  methods  represented  in  Fig.  675.  Set 
the  teeth  or  blocks  in  the  temporary  plaster  rim  and  distinctly 
mark  a  line  around  the  ridge,  just  under  the  head  of  the  pins  (C); 
mark  across  this  line  the  position  of  each  pin  (a,  b,  c,  d)  ;  then  remove 
blocks  and  prepare  the  plate  for  the  different  plans  of  retaining  the 
vulcanite.  1st.  For  an  aluminum  plate  which  can  have  no  soldered 
pins,  drill  a  row  of  small  holes  on  the  line  between  the  pins ;  set  it  in 


886  MECHANICS. 

the  counter-die,  and,  with  a  tapering  punch,  enlarge  each  hole,  with 
the  projecting  burr  next  the  tooth  (C,  c).  Let  each  hole  be  not  smaller 
than  oSTo.  20  (Fig.  512).  In  some  cases  a  smaller  set  of  holes  may  be 
punched  or  drilled  in  the  outer  edge  above  the  gum  (C).  Swage  the 
plate  again,  to  correct  the  effect  of  this  punching ;  then  place  it  on 
model,  replace  blocks,  arrange  wax,  and  prepare  for  vulcanizing. 
2d.  Arrange  the  plate  firmly  on  a  piece  of  charcoal,  set  small  cups 
of  gold  or  platina  on  the  line,  between  the  pins  (A,  a),  with  a  small 
piece  of  solder  at  each,  and  solder  them  all  at  one  heating.  3d.  Or 
drill  small  holes  on  the  line,  between  the  pins  of  the  teeth  (B,  b),  and 
insert  headed  platina  or  gold  pins,  and  solder  them.  4th.  Or  drill 
two  holes  between  the  tooth-pins  (E,  e)  and  insert  a  loop ;  only  one 
hole  is  really  necessary,  as  the  other  end  of  the  loop  may  be  short- 
ened so  as  just  to  touch  the  plate,  to  which  the  solder  will  attach  it. 
5th.  Lastly,  a  wire  may  be  bent  in  a  series  of  waves  (c?),  so  as  to  pass 
under  each  tooth-pin  (or  just  behind  it,  if  the  pin  is  too  close  to  the 
plate,  but  never  over  it)  and  rise  from  the  plate,  between  the  pins. 

Fig.  675. 


Adjust  this  wire  accurately,  with  the  blocks  in  place  ;  mark  the  points 
of  contact ;  then  remove  plate  and  solder  the  wire.  The  last  four 
methods  are  applicable  to  gold  and  platinum,  which  admit  of  solder- 
ing. In  soldering,  no  plaster  investment  must  be  used,  and  the  plate 
must  have  a  good  support  on  the  charcoal ;  with  these  precautions, 
careful  soldering  will  not  warp  or  spring  the  plate.  If  sprung,  the 
pins  and  loops  make  it  necessary  to  cut  a  deep  groove  in  the  lead 
counter-die  before  attempting  to  swage. 

After  completing  either  of  the  five  plans  here  described,  re-adjust 
the  teeth  in  the  plaster  rim  and  fasten  them  in  place  with  wax, 
trimmed  to  the  shape  required  for  the  vulcanite ;  then  invest  in  the 
flask  and  vulcanize  as  before  described.  By  avoiding  excess  of  rub- 
ber, using  only  so  much  as  is  necessary  to  conceal  the  pins  or  loops, 
the  vulcanite  band  may  have  a  very  neat  appearance.  Some  dentists 
partly  conceal  the  rubber  by  an  inside  and  outside  band ;  but  if  con- 
cealment is  necessary,  we  should  prefer  to  do  it  by  the  form  of  blocks 


VULCANO-PLASTIC   WORK.  887 

above  given.  If  the  inside  band  is  used,  the  simplest  method  is  to 
mark  the  line  of  its  position  ;  then,  by  skillful  use  of  the  hammer,  a 
strip  of  gold  can  be  paned  and,  with  the  pliers,  bent  so  as  to  have  a 
uniform  slope  and  a  close  fit ;  a  file  will  be  necessary  over  small  promi- 
nences; this  method  of  paning  is  simpler  than  either  swaging  a  band 
or  first  making  a  lead  or  tin  pattern.  If  cast  plates  of  aluminum  or 
other  metal  alloys  are  used,  it  is  only  necessary  to  drill  holes,  as  many, 
and  of  such  size,  as  may  be  thought  necessary,  in  that  part  of  the 
plate  next  the  blocks ;  they  may  pass  through  to  the  palatine  surface 
if  necessary,  and  be  countersunk.  It  is  very  important  to  ascertain, 
by  trial,  that  the  closely  fitting  edge  of  aluminum  does  not  interfere 
with  the  teeth,  in  separating  and  replacing  the  flask. 

A  method  of  attaching  porcelain  teeth  to  a  metal  base  with  vul- 
canite, was  devised  by  Dr.  P.  G.  C.  Hunt,  and  a  process  very  similar 
was  afterwards  introduced  by  Dr.  Engle.  It  is  described  by  Dr.  Hunt 
as  follows :  "  Thus  far  we  proceed  as  we  do  for  ordinary  gold  plate 
work.  We  will  now  suppose  the  teeth  ground  and  jointed,  leaving  as 
much  space  between  the  teeth  and  plate  as  the  plate  will  admit  of. 
We  next  mark  with  a  sharp-pointed  instrument,  on  the  labial  surface 
of  the  plate,  each  point  where  it  is  necessary  to  place  a  loop,  for  pur- 
poses hereinafter  described ;  then  apply  wax  to  the  external  or  labial 
parts  of  the  teeth  and  plate,  in  any  manner  sufiicient  to  retain  the 
teeth  in  position ;  remove  the  wax  from  the  lingual  parts  of  the  teeth 
and  plate,  and  mark  the  position  on  the  metal  where  it  is  desirable  to 
insert  the .  loops ;  remove  the  teeth  and  wax,  and  with  a  small  bow- 
•  drill  make  holes  through  the  plate  at  the  several  points  previously 
determined  on  for  the  attachments,  about  the  size  of  an  ordinary  plate- 
punch  hole;  take  a  wire,  or  ordinary  gold  plate  cut  in  strips,  say  from 
a  half  to  one  line  in  width,  being  governed  by  the  amount  of  room 
there  is  under  the  base  of  the  teeth,  and  with  small  round-nosed  pliers 
bend  the  strip  around ;  grasp  both  ends  with  square-nosed  pliers ; 
draw  the  round-nosed  pliers  from  the  loop,  still  grasping  the  square- 
nosed  pliers  with  the  left  hand,  and  with  a  hammer  strike  the  top  of 
the  loop  a  sufiicient  blow  to  keep  the  ends  from  springing  apart ;  cut 
ofi*  the  ends  and  dress  down  to  fit  the  holes  in  the  plate ;  after  which 
solder  on  charcoal  or  other  suitable  substance  without  investment. 
Fig.  676  illustrates  the  bent  or  hooked  wires  soldered  to  the  base. 
Pickle,  dress,  and  polish  that  portion  of  the  plate  to  be  exposed  to 
view.  Bend  and  flatten  the  pins  ;  arrange  the  teeth,  waxing  so  as  to 
cover  up  the  loops  if  practicable.  The  loops  should  be  placed  as  near 
the  base  of  the  teeth  as  possible,  the  rubber  forming,  when  finished,  a 
part  of  the  general  concave  shape  which  is  desirable  in  upper  dentures, 
and  which  it  is  not  possible  to  obtain  with  ordinary  soldered  work. 


MECHANICS. 


Then  with  silicate  of  soda  paint  the  joints,  to  keep  the  rubber  from 
forcing  in  where  it  would  show  after  vulcanizing.  Flask,  vulcanize 
and  finish  as  usual. 

Celluloid  can  be  attached  to  a  metal  plate  with  the  same  loops  and 
hooks,  by  sawing  out  the  palatal  portion  of  the  celluloid  blank,  and 
trimming  away  as  much  of  the  remaining  portion  which  covers  the 
alveolar  ridge  as  is  necessary  to  avoid  having  an  excess  of  material. 
When  investing  the  piece,  the  line  of  separation  is  made  at  the  edge 
of  the  wax  rim,  thus  permitting  the  plaster  to  cover  the  palatal  por- 
tion of  the  metal.  When  the  sections  of  the  flask  are  separated,  the 
metal  plate  will  occupy  the  lower  and  the  teeth  the  upper  portions. 

The  attachment  of  vulcanite  to  metal  plates  is  an  extremely  useful 
and  important  application.  It  loses  one  of  the  peculiar  advan- 
tages claimed    for  vulcanite,  the    accurate  fit  of  the  plate ;   but    it 

Fig.  676. 


makes  very  strong  work,  and  is  more  cleanly  than  ordinary  swaged 
work,  because  all  interstices  are  completely  closed.  It  also  gives  a 
shape  behind  the  teeth  more  conformable  to  the  natural  shape  of  the 
teeth  and  gum.  It  obviates  two  of  the  principal  objections  urged 
against  vulcanite — thickness  of  the  plate  and  contact  of  the  rubber 
against  the  gum  and  tongue.  It  dispenses  with  that  accurate  grinding 
of  the  base  of  blocks  required  in  ordinary  gold  work,  and  obviates 
the  risks  of  the  soldering  process.  It  is  applicable  to  full  sets,  or  to 
partial  sets  where  the  teeth  are  in  groups  of  three  or  more.  It  is  best 
repaired  by  removing  the  entire  vulcanite  attachment ;  but  those  who 
patch  up  old  rubber  plates  can,  with  greater  impunity,  patch  the 
"  combination  work  ;  "  since  the  strength  of  the  piece  depends  mainly 
on  the  plate,  the  brittleness  of  second  heating  is  of  less  moment. 
Another  argument  in  its  favor  is,  that  it  makes  available   to  gold- 


VULCANO-PLASTIC  WORK.  889 

dentists  the  beautiful  forms  of  rubber  blocks,  without  identifying  them 
with  that  class  of  rubber-dentists  who,  by  accommodating  the  style 
of  their  work  to  the  cheapness  of  the  material,  have  brought  much 
discredit  upon  dental  mechanism.  A  vulcanite  plate  may  be 
bleached  by  placing  it  in  a  glass  vessel  containing  alcohol,  and 
exposing  to  the  sun's  rays  for  from  four  to  six  hours  ;  covering  the 
top  of  the  vessel  with  a  plate  of  glass  will  prevent  rapid  evaporation. 
The  pink  rubber  employed  to  give  a  more  natural  color  to  the  gum 
requires  to  be  bleached  in  order  to  render  it  sightly.  To  remove  teeth 
from  a  vulcanite  plate,  the  piece  may  either  be  passed  through  an 
alcohol  flame  until  they  become  hot,  or  the  set  may  be  boiled  in  oil, 
or  imbedded  in  hot  sand  of  such  a  temperature  as  will  not  char  the 
plate.  The  latter  method  is  preferable  when  care  is  taken  to  have  the 
sand  at  a  proper  temperature,  as  the  teeth  or  sectional  blocks  can  be 
readily  detached,  and  all  rubber  adhering  to  the  pins  be  removed  by 
means  of  a  pointed  excavator.  Any  slight  imperfections  in  a  vulcanite 
plate,  in  the  form  of  a  small  hole  left  by  plaster  particles,  can  be 
repaired  by  melting  gum  shellac  and  incorporating  it  with  vulcanite 
filings.  A  cement  thus  formed  can  be  introduced  in  a  plastic  state 
and  made  smooth  with  a  heated  spatula  or  burnisher. 

Rubber  can  be  made  liquid  for  use  as  a  rubber  solder  by  cutting  it 
into  small  pieces  and  dissolving  by  either  benzine,  turpentine,  chloro- 
form, ether  or  bisulphide  of  carbon,  all  of  these  agents  being  solvents 
of  rubber.  The  shape  of  a  vulcanite  plate  can  be  changed  by  obtain- 
ing a  correct  impression  and  model  of  the  mouth,  upon  which  the 
plate,  having  been  previously  heated,  is  pressed  by  means  of  a  napkin 
or  piece  of  chamois  skin,  and  held  in  position  until  it  is  cold.  To 
soften  the  rubber  plate,  the  set  may  be  immersed  in  boiling  water,  or 
placed  in  an  oven  with  the  teeth  downward,  until  the  rubber  becomes 
pliable ;  in  the  latter  method  care  being  taken  that  the  rubber  is  not 
blistered  or  charred.  A  more  certain  method,  however,  is  to  recon- 
struct the  set. 

For  quick  repair  in  the  case  of  a  broken  tooth  or  sectional  block,  a 
hard,  quick-setting  amalgam  is  sometimes  employed,  first  cutting  out 
a  suitable  cavity  about  the  space  to  be  filled,  and  after  the  tooth  is 
properly  adjusted,  packing  the  amalgam  under  it  and  about  the  pins, 
the  tooth  being  firmly  held  in  place  during  the  operation.  Wood's 
fusible  metal  has  also  been  used  for  the  same  purpose,  and  to  close 
holes,  the  latter  being  countersunk  on  both  surfaces,  and  made  oblong. 

Spring  plates  consist  of  elastic  partial  pieces,  which  are  so  constructed 
and  vulcanized  as  to  press  against  certain  natural  teeth, and  thus  be  re- 
tained in  position.  After  securing  the  model,  a  little  of  the  palatal 
surfaces  of  the  plaster  bicuspids  and  molars  is  scraped  away,  and  in 


890  MECHANICS. 

forming  the  trial  plate  the  wax  is  allowed  to  extend  some  distance 
from  the  necks  of  the  retaining  teeth,  upon  the  model,  toward  the 
grinding  surfaces,  in  the  form  of  partial  stays.  These  plates  are  so 
shaped  as  to  leave  the  central  portion  of  the  mouth  free,  no  air- 
chambers  or  clasps  being  necessary.  As  the  tendency  of  spring  plates 
is  to  press  the  retaining  teeth  outward,  they  are  not  generally  used. 
For  mouths  having  soft  places,  Dr.  Land  recommends  an  air  chamber 
covering  four-fifths  of  the  palatine  arch,  and  including  certain  parts  of 
the  alveolar  walls  (Fig.  621)  ;  and  the  same  writer  remarks  :  "To  insure 
a  comfortable  adaptation,  the  pressure  must  be  so  equalized  that,  as  the 
alveolar  ridge  recedes,  undue  stress  will  not  be  brought  on  the  hard 
palate.  For  this  reason  an  air  space,  covering  almost  the  entire  sur- 
face of  the  palatine  arch,  is  desirable,  as  thus  the  pressure  is  better 
distributed  and  brought  to  bear  directly  on  the  alveolar  ridge,  where 
there  will  be  the  least  danger  of  injuring  the  mouth,  and  thus  avoiding 
the  riding  or  rocking  of  the  plate  on  the  hard  palate.  The  conven- 
tional air  chamber,  with  its  acute  angles  invariably  placed  on  the  most 
rigid  portion  of  the  hard  palate,  soon  outlines  itself  in  the  tissues, 
demonstrating  a  failure  to  properly  utilize  atmospheric  pressure,  and 
injuring  the  mouth  by  inducing  absorption  unnecessarily." 

Dr.  Hurd  has  suggested  what  he  terms  a  "flange  suction,"  for  lower 
plates,  which  is  described  as  follows :  An  impression  is  first  taken  in 
wax,  and  this  is  used  to  obtain  a  plaster  impression.  The  extreme 
projecting  plaster  at  the  sides  of  the  tongue  is  cut  ofi^,  and  the  surface 
varnished  and  filled  up,  so  as  to  make  a  full  model  across  from  heel 
to  heel,  running  far  back  upon  the  process,  to  keep  the  lip  from 
pressing  the  plate  back  when  the  force  of  the  muscles  and  lip  is 
brought  to  bear  upon  it.  After  obtaining  a  correct  articulation,  a 
gutta-percha  plate  being  used  for  the  purpose,  the  teeth  are  set  directly' 
upon  the  centre  of  the  margin,  perpendicular  in  front,  but  inclined  at 
the  sides,  so  as  to  allow  for  a  sufficient  space  to  form  an  outer  flange 
for  the  lip  to  press  down  upon.  This  flange  is  then  made,  by  means  of 
wax,  about  one-third  of  an  inch  thick,  with  the  inner  surface  rounded 
up  in  the  same  manner  as  the  outside,  but  not  made  so  thick  and  high, 
for  the  tongue  to  rest  upon  and  keep  down,  thus  excluding  the  air, 
the  saliva  which  collects  under  the  tongue  also  aiding  in  making  the 
vacuum.  It  is  necessary  that  the  flange  should  rest  gently  against 
the  cheek,  to  give  steadiness  to  the  plate,  and  the  teeth  must  be  so 
arranged  that  they  are  level  on  the  face.  After  vulcanizing,  the  piece 
is  first  cut  away  by  filing,  at  the  hard  margin  on  the  under  side  of  the 
outside  flange,  and  increasing  it  near  the  edge  of  the  plate  at  the 
cheek,  and  making  a  chamber.  The  inside  of  the  plate  is  also  cut 
away,  to  free  it  from  the  sublingual  muscles  and  glands,  which  tend  to 


VULCANO-PLASTIC   WOEK.  891 

elevate  the  plate  when  the  tongue  moves  upward.  In  cases  of  mal- 
formation a  thin,  flexible  rubber  flange  may  be  attached  to  the  plate, 
instead  of  the  hard  flange,  so  as  to  hold  securely  and  conform  to  the 
movements  of  the  muscles. 

Vulcanite  for  Irregularity  Ajypliances. — Of  the  peculiar  adap- 
tation of  the  vulcanite  material  to  the  correction  of  irregularity  men- 
tion has  been  made  in  the  chapter  on  that  subject.  No  further  special 
directions  are  required,  except  on  two  points;  first,  to  have  the  plaster 
which  makes  the  model  perfectly  smooth  and  free  from  air  bubbles  ; 
secondly,  to  coat  the  teeth,  befox-e  vulcanizing,  with  soluble  glass  or 
collodion  solution.  Attention  to  these  two  points  will  give  a  plate 
which,  if  the  impression  is  correct,  will  fit  the  teeth  with  most  perfect 
accuracy. 

Directions  to  Patient. — Upon  the  completion  and  insertion  of  a  vul- 
canite piece,  the  patient  should  be  cautioned  to  cleanse  it  thoroughly 
at  least  once  a  day ;  also  to  keep  it  in  water  Avhen  not  worn  in  the  mouth. 
Extreme  cleanliness  is  advisable  in  all  kinds  of  artificial  work,  and 
many  patients  need  no  such  direction  ;  the  special  necessity  for  care, 
in  the  case  of  vulcanite,  arises  from  the  tenacity  with  which  the  mucous 
secretions  adhere  to  the  surface  if,  from  neglect,  they  are  allowed  to 
collect  upon  it.  This  coating  is  most  apt  to  collect  at  those  points 
where  the  friction  of  the  tongue  and  of  the  food  does  not  remove  it; 
the  same  care  is  necessary  for  its  daily  removal,  as  is  required  to  keep 
the  natural  teeth  in  good  order.  There  is,  however,  this  difference  be- 
tween cleanliness  of  the  teeth  and  of  the  plate ;  that  while  both  are 
essential  to  purity  of  the  mouth,  the  secretions  have  no  chemical  action 
upon  the  plate,  as  they  have  upon  the  teeth. 

One  point  affecting  the  durability  of  vulcanite  plates  has,  perhaps, 
not  been  determined  by  a  sufficient  experience.  It  is  well  known  that 
silver  and  eighteen-carat  gold  undergo  a  change  in  the  mouth,  which 
causes  them  to  become  more  or  less  brittle ;  such  is  not  the  case  with 
twenty-carat  gold  and  with  platinum.  The  change  in  these  cases  is  partly 
the  effect  of  mastication,  acting  as  do  the  repeated  blows  of  swaging ; 
partly  a  galvanic  action  between  the  molecules  of  the  alloyed  metal. 
A  similar  but  much  more  rapid  change  takes  place  in  the  gutta-percha 
which  is  used  for  imjDressions ;  also  in  the  vulcanized  gutta-percha  and 
in  all  those  preparations  of  vulcanized  rubber  with  which  foreign  sub- 
stances are  largely  mixed  for  the  purpose  of  modifying  the  brown  or 
red  color.  The  brown  rubber,  being  purer,  will  probably  retain  its 
toughness  and  elasticity  longer  than  the  red  rubber.  We  have  some 
specimen  pieces  of  red  rubber  which  seem,  at  the  end  of  twelve  years, 
to  possess  their  original  strength  ;  and  we  know  of  one  partial  piece  that 
has  been  worn  constantly  for  ten  years,  which  has  never  been  repaired, 


892  MECHANICS. 

and  seems  as  strong  as  when  first  made.  This  point,  however,  requires 
the  collected  experience  of  many  observers,  during  a  period  of  many- 
years,  carefully  distinguishing  between  the  brittleness  of  over-baking 
or  twice  vulcanizing,  and  that  which  may  supervene  as  the  result  of 
certain  molecular  changes  in  the  substance  of  the  material.  It  is  a 
change  which,  unlike  the  galvanic  action  in  gold  and  silver  plate,  may 
not  require  the  presence  of  the  buccal  fluids,  but  which  will  probably 
take  place  alike  out  of  the  mouth  as  in  ;  for  such  is  shown  to  be  the 
case  with  gutta-percha. 

"  Against  the  use  of  the  vulcanite  it  is  urged  :  1,  That  it  has  de- 
graded the  art  by  the  extent  to  which  it  has  introduced  cheap  work, 
and  by  the  ease  with  which  its  peculiar  manipulations  are  performed. 
2.  That  its  medicinal  action  upon  the  system  is  such  as  to  render  it 
an  unfit  material  to  be  put  into  the  mouth.  3.  That  it  produces  an 
unpleasant  burning  or  heating  sensation  in  the  mucous  membrane, 
and  a  permanent  sponginess  of  the  gums,  not  attendant  on  the  wearing 
of  metallic  plates.  4.  That  the  mucous  secretions  require  more  care 
for  their  removal  from  the  surface  of  the  plate  than  most  patients 
are  in  the  habit  of  giving ;  hence  the  liability  of  the  piece  to  become 
unpleasant.  5.  That  to  give  the  necessary  strength  requires  a  thick- 
ness of  plate  that  is  clumsy  and  interferes  with  distinctness  of  enuncia- 
tion. 6.  That  the  work  becomes  brittle  in  the  course  of  a  few  years. 
7,  That  it  is  troublesome  to  repair  in  such  a  way  as  to  maintain  its 
original  strength. 

"  In  favor  of  the  use  of  vulcanite  it  is  urged  :  1.  That  the  absolutely 
perfect  and  unfailing  accuracy  of  its  adaptation  to  the  model  places  it, 
in  this  important  respect,  before  every  other  material  in  use  for  dental 
plates.  2.  That,  being  perfectly  impervious  to  fluids  and  insoluble, 
it  is  a  pure  and  harmless  material.  3.  That,  being  devoid  of  all  gal- 
vanic action,  it  is  more  agreeable  to  patients  than  soldered  and  alloyed 
plates.  4.  That  it  has  none  of  the  wearing  action  of  metal  upon  teeth 
against  which  it  becomes  necessary,  in  partial  cases,  to  bring  it  in 
contact.  5.  That  the  great  lightness  of  the  material  makes  it  very 
pleasant  to  the  patient,  and  permits  the  filling  out  of  deficiencies  in 
the  ridge  with  the  least  possible  addition  to  the  weight  of  the  piece. 

6.  That  this  lightness,  together  with  its  peculiar  elasticity,  lessen  greatly 
the  danger  of  accidental  breakage  of  either  teeth  or  plate;  thus  making 
it,  when  properly  constructed,  the  strongest  of  all  dental  substitutes. 

7.  That  the  plastic  properties  of  the  vulcanite  and  the  readiness  with 
which  it  may  be  moulded  and  hardened  against  any  surface,  however 
irregular,  give  it  a  wider  range  of  applicability  than  any  other  substance 
used  in  dentistry." 


CELLULOID.  893 

CELLULOID. 

Celluloid,  like  vulcanized  rubber,  a  cheap  base  for  artificial  dentures, 
was  first  introduced  in  1869,  and  during  the  existence  of  the  "  rubber 
patents  "  was  much  used  by  those  who  objected  to  become  licensees  of 
the  Goodyear  Rubber  Company.  The  comparatively  recent  improve- 
ments made  in  the  material,  and  methods  of  manipulating  it,  have 
commended  celluloid  to  professional  favor  as  a  plastic  substance  more 
in  harmony  with  the  soft  tissues  of  the  mouth,  as  regards  natural  gum 
color,  than  rubbei',  although  it  is  more  liable  than  the  latter  substance 
to  change  form  after  moulding,  and  to  absorb  the  oral  secretions,  if 
not  properly  manipulated.  Celluloid  is  obtained  from  cellulose,  the 
woody  fibre  which  constitutes  the  framework  of  plants,  examples  of 
which  are  furnished  by  hemp,  linen,  cotton-wool,  etc.  In  the  manu- 
facture of  celluloid,  the  cellulose  of  hemp,  which  is  the  strongest,  is 
first  converted  into  paper  by  the  usual  method,  its  chemical  properties 
during  this  process  remaining  unchanged.  The  hemp  paper  is  then 
converted  into  pyroxylin  (gun  cotton),  by  immersing  the  paper  in  a 
strong  mixture  of  nitric  and  sulphuric  acids,  afterward  being  tho- 
roughly washed. 

This  process  increases  its  weight  about  seventy  per  cent,  and  renders 
it  highly  explosive,  taking  fire  at  300°  Fahrenheit, 

The  pyroxylin  is  then  reduced  to  a  pulp,  and  a  mixture  made  of  the 
following  ingredients :  Pyroxylin,  100  parts ;  camphor,  40  parts  ;  oxide 
of  zinc,  2  parts  ;  vermilion,  0.6  parts.  It  will  be  seen,  therefore,  that 
celluloid  is  composed  principally  of  pyroxylin,  with  camphor  (dissolved 
in  alcohol)  as  a  solvent,  and  that  it  contains  less  vermilion  than  the 
red  vulcanizable  rubbers.  After  the  ingredients  are  thoroughly  mixed, 
immense  pressure  is  brought  to  bear  upon  the  mass,  by  means  of  a 
hydraulic  press  of  two  thousand  pounds  to  the  square  inch,  which 
squeezes  the  celluloid  through  a  small  orifice  in  the  side,  near  the 
bottom,  of  a  strong  cylinder.  This  pressure  is  necessary  to  condense 
and  solidify  the  celluloid,  which,  as  it  presses  out  of  the  orifice  in  the 
cylinder  is  cut  into  pieces  and  moulded  by  heat  and  pressure  into 
forms  suitable  for  dental  use,  called  "  blanks,"  and  which,  in  size  and 
shape,  approximate  to  the  bases  of  upper  and  lower  dentures.  These 
"  blanks  "  are  then  seasoned  for  some  two  months,  in  a  room  kept  at  a 
temperature  of  160°  Fahrenheit,  when  they  are  ready  for  use.  To 
manipulate  a  celluloid  blank  into  a  proper  denture  is  by  no  means  as 
easy  an  operation  as  the  working  of  vulcanizable  rubber,  celluloid 
being  a  material  that  is  liable  to  alteration  in  shape  and  character 
under  different  circumstances.  Repeated  failures  are  the  result  of 
manipulating  celluloid  like  vulcanizable  rubber  ;  hence  perfect  moulds, 
equal  pressure,  and  metal  dies  are  absolutely  necessary  for  the  useful- 


894 


MECHANICS. 


nes3  and  durability  of  such  a  denture.  Experience  proves  that  metal 
dies,  which  produce  a  surface  proof  against  disintegration,  are  alone 
reliable.  The  coating  of  the  surface  of  a  wax  and  paraffine  plate,  and 
also  of  the  plaster  model,  with  tin  foil,  overcomes  somewhat  the  diffi- 
culty of  preventing  the  loss  of  too  much  of  the  camphor  solvent  by 
absorption,  and  obviates  the  necessity  of  removing  the  original  surface 
possessed  by  a  celluloid  plate  when  it  is  taken  from  the  heater. 

In  the  preparation  of  a  celluloid  denture,  the  manipulations  are  the 
same  as  for  vulcanized  rubber,  until  the  case  is  ready  to  invest  in  the 
flask.  The  plaster  used  for  working  celluloid  should  be  of  the  best 
quality,  and  not  mixed  too  thin.  The  pink  paraffine  and  wax  answers 
better  than  any  other  material  for  a  base  plate ;  a  thin  paraffine-and- 
wax  sheet  being  used  for  the  plate,  which  is  strengthened  by  adding 
to  its  surface  either  warmed  paraffine  or  modeling  composition,  first 

Fig.  677. 


covering  the  paraffine  plate  with  No.  60  tin  foil,  in  order  that  the 
modeling  composition  may  be  removed  without  injuring  the  smooth 
surface  of  the  thin  paraffine  base  plate.  The  teeth  are  arranged  upon 
the  base  plate  and  secured  by  dropping  melted  paraffine  and  wax 
around  their  roots.  A  stick-form  of  paraffine  and  wax  can  be  ob- 
tained, which  is  very  convenient,  the  method  of  using  it  being  repre- 
sented in  Fig.  677. 

The  paraffine  and  wax  compound  is  then  carved  into  the  shape  of  the 
gum  desired,  by  carving  instruments,  such  as  the  set  of  Dr.  "W.  "W. 
Evans,  represented  in  Fig.  645 ;  or  a  simple  scraper  may  be  used,  such 
as  is  represented  in  Fig.  678.  The  surface  of  the  paraffine  and  wax  may 
be  made  very  smooth  by  directing  upon  it  the  flame  of  an  alcohol 
lamp  with  a  blowpipe,  care  being  taken  to  preserve  the  outlines  of  the 
carved  gum.    The  more  perfectly  the  wax  is  carved  and  smoothed,  the 


CELLULOID. 


895 


less  finishing  of  the  surface  of  the  celluloid 
will  be  necessary.  The  surface  of  the  wax 
is  then  covered  with  heavy  tin  foil,  which  is 
burnished  down  lightly  and  smoothly. 

The  case  is  now  ready  for  investing  or 
flaskiug,  after  which  the  grooves  are  cut  for 
excess  of  material ;  and  in  every  case  the 
parting  of  the  flask  should  be  at  the  edge  of 
the  wax,  and  the  wax,  teeth  and  foil  removed 
with  the  upper  half  of  the  flask,  so  that  the 
surface  of  the  model  or  cast  is  left  clean  and 
entirely  exposed. 

To  prevent  breaking  a  plaster  cast,  in  cases 
of  deep  undercut,  the  method  of  investment 

Fig.  679. 


Fig.  678. 


iml 


suggested  by  the  late  Dr.  Wildman  should 
be  followed.  "  It  consists  simply  in  so  invest- 
ing the  cast  that  it  shall  occupy  the  position 
shown  in  Fig.  679.  If  so  placed,  the  pressure 
applied  in  moulding  is  brought  to  bear  upon 
the  mass  of  plaster  supporting  the  projec- 
tion, instead  of  upon  a  thin  section."  Cut- 
ting away  the  base  of  the  cast  at  the  heel, 
before  investing  it,  will  elevate  the  anterior 
part  in  the  manner  referred  to.  After  the 
sections  of  the  flask  are  separated,  the  wax 
is  removed  by  pouring  boiling  water  upon 
it  from  the  spout  of  a  kettle,  when  the  tin 
foil  will  remain  upon  the  plaster  surface. 
In  some  cases  it  may  be  necessary  to  cut  away  the  thin  edge  of  plaster 
which  projects  over  the  mould,  in  the  section  of  the  flask  containing 
the  teeth.  It  is  recommended  to  cut  a  groove  for  excess  of  material 
around  the  inside  of  the  flask,  about  one-eighth  of  an  inch  from  the 
model,  and  in  this  section  of  the  flask,  with  no  cross  grooves  connecting 


896 


MECHANICS. 


the  main  groove  with  the  model,  as  is  done  in  the  case  of  vulcanite. 
All  sharp  edges  of  plaster  liable  to  break  off  should  be  removed  or 
rounded,  and  many  prefer,  especially  when  gum  teeth  are  used,  to  cut 
away  the  plaster  between  the  model  and  the  edge  of  the  flask,  all 
around,  about  the  thirty-second  of  an  inch,  to  allow  the  surplus  cellu- 
loid to  escape  without  pressing  too  much  upon  the  gums  of  the  teeth. 
In  using  a  celluloid  blank,  care  should  be  taken  to  select  one  as  near 
the  size  of  the  surface  of  the  model  as  possible,  for  all  folding  owing 

Fig.  680. 


to  too  great  width  at  the  sides  will  form  creases  in  the  plate.  Cellu- 
loid may  be  moulded  with  steam,  glycerine  or  oil,  and  by  dry  heat,  the 
latter  giving  the  most  perfect  results.  Fig.  680  represents  a  sectional 
diagram  of  the  steam  moulding  apparatus  of  the  Celluloid  Manufac- 
turing Company. 

In  using  this  steam  apparatus  the  boiler  is  partly  filled  with  water, 
the  quantity  being  sufficient  to  cover  the  ribs  at  the  bottom..    The 


CELLULOID.  897 

screw  is  turned  back  so  far  that  the  plunger  when  in  position  is  resting 
against  the  top  of  the  boiler,  so  that  the  model  may  not  be  injured  by 
pressure  upon  the  flask  while  the  cover  is  being  screwed  down.  It  is 
very  necessary  that  the  cover  should  be  well  turned  down,  the  gland 
turned  back,  and  the  screw  working  easily,  otherwise  it  is  impossible 
to  determine  how  much  pressure  is  exerted  ;  for,  if  too  much,  the  teeth 
or  model  may  be  broken,  and  if  too  little,  the  result  is  a  porous  plate. 
After  the  flask  is  placed  in  the  apparatus,  the  screw  is  turned  down 
very  gently  with  the  thumb  and  finger,  until  it  is  felt  to  touch  the 
flask.  The  heat,  which  may  be  generated  with  alcohol,  kerosene  or 
gas,  is  then  applied.  The  upper  portion  of  the  safety  valve,  which 
consists  of  two  parts,  may  be  suspended  by  the  pins  in  the  lead  weight, 
and  this  valve  should  not  allow  the  steam  to  escape  at  a  temperature 
of  225°  F.  When  the  steam  begins  to  blow  off,  strict  attention  is 
-necessary,  as  the  plate  is  readily  injured  by  too  much  heat  without  the 
required  pressure.  The  time  necessary  from  this  point,  with  the 
properly  regulated  heat,  is  from  fifteen  to  twenty  minutes.  When 
the  steam  escapes  from  the  valve,  its  upper  portion  being  suspended, 
the  plate  begins  to  soften,  and  the  screw  is  easily  turned  with  the 
thumb  and  finger,  when  the  upper  weight  should  be  dropped  down. 
The  screw  is  again  turned  very  carefully,  the  pressure  ceasing  as  soon 
as  resistance  is  felt,  and  continued  when  it  again  yields.  This  careful 
screwing  down  is  kept  up,  and  the  pressure  somewhat  increased  as  the 
steam  rises,  which  can  be  determined  by  raising  the  valve,  the  object 
being  to  exert  an  equal  pressure  over  the  entire  plate,  before  the  steam 
blows  off*  very  sharply  and  .  continuously  on  raising  the  safety  valve. 
At  this  point  in  the  moulding  process  the  pressure  should  be  increased, 
but  an  interval  elapse  between  the  turns  of  the  screw,  in  order  to  allow 
the  celluloid,  which  flows  very  slowly,  to  escape  under  the  pressure. 
At  the  end  of  the  process,  considerable  pressure  should  be  exerted  by 
means  of  the  screw,  as  much,  indeed,  as  can  be  applied,  or  until  the 
screw  can  no  longer  be  turned.  If  alcohol  is  used  to  generate  the 
heat,  the  cup  of  the  apparatus  is  of  such  a  size  that  its  contents  are 
consumed  by  the  time  the  steam  blows  off*  from  the  safety  valve,  and 
the  moulding  is  completed.  If  gas  or  kerosene  is  employed,  the  flame 
should  be  so  regulated  as  to  complete  the  moulding  process  within 
thirty  to  forty  minutes,  otherwise  the  celluloid  may  be  injured. 

To  mould  celluloid  in  glycerine  or  oil  an  apparatus  represented  by 
Fig.  681  is  employed.  It  consists  of  an  open  tank  to  contain  the 
glycerine,  with  a  thermometer  to  indicate  the  heat,  a  stand  on  detach- 
able legs,  and  a  screw  clamp  to  hold  the  flask.  In  the  use  of  the 
glycerine  apparatus,  when  the  case  is  ready  for  moulding,  the  celluloid 
blank  is  placed  in  the  flask,  which  is  then  put  in  the  screw  clamp,  and 

57 


898 


MECHANICS. 


the  screw  turned  until  it  lightly  presses  upon  the  top  of  the  flask. 
The  whole  case  is  then  placed  in  the  tank  and  sufficient  glycerine 
poured  in  to  cover  the  flask — about  one  and  a  half  pounds. 

The  heat  (which  may  be  generated  by  alcohol,  gas,  or  kerosene)  is 
then  applied,  and  as  soon  as  its  eflTect  is  felt  by  the  screw  yielding  to 
slight  pressure,  about  225°  F.,  the  moulding  process  is  commenced. 
The  screw  should  be  very  gently  turned  at  first,  and  the  pressure  regu- 
lated by  the  softening  of  the  celluloid,  and  increased  as  the  flask 
closes.  The  flask  in  the  clamp  can  be  removed  from  the  tank  at 
times,  to  note  the  progress  of  closing  of  the  flask,  which  should  take 
place  evenly,  so  as  to  distribute  the  pressure  equally  over  the  entire 
plate.     The  heat  should  not  rise  above  280°  F.,  and  if  the  flask  is  not 

Fig.  681. 


closed  completely  when  this  temperature  is  reached,  the  flame  may  be 
reduced.  Olive  or  lard  oil  may  be  used  instead  of  glycerine,  but 
the  latter  is  preferable,  on  account  of  cleanliness.  In  using  steam  or 
glycerine,  the  flask  should  remain  in  the  clamp  until  it  has  become 
cold ;  the  cooling  may  be  hastened  by  immersing  the  clamp  and  flask 
in  cold  water.  Where  the  plate  is  of  unusual  thickness,  or  the  blank 
is  changed  in  shape  to  accommodate  it  to  the  case,  it  is  recommended 
to  place  the  flask,  secured  in  a  clamp,  near  a  stove,  at  a  temperature 
not  exceeding  140°  F.,  for  at  least  half  a  day,  in  order  to  avoid  the 
danger  of  warping  the  plate.  It  is  also  necessary,  in  the  use  of  the 
steam  apparatus,  to  put  sufficient  water  in  the  heater,  as  too  small  a 


CELLULOID. 


899 


quantity  may  be  entirely  converted  into  steam,  which  is  liable  to  be- 
come overheated,  a  result  which  is  not  only  dangerous,  but  injurious  to 
the  celluloid. 

In  moulding  celluloid  by  means  of  hot,  moist  air,  several  forms  of 
apparatus  may  be  used,  one  of  the  most  prominent  of -which  is  the 
"Best  "  Hot  Moist  Air  Celluloid  Apparatus,  represented  in  Fig.  682. 

In  using  the  "  Best  "  Apparatus,  the  plaster  iu  the  flask  should  be 
made  very  wet,  by  placing  it  in  a  vessel  of  water,  before  it  is  put  into 
the  heater.  After  this  is  done  the  flask  is  placed  in  the  clamp,  the  top 
of  which  is  screwed  down  until  it  comes  in  contact  with  the  flask.     It 


Fig.  682. 


RIGGED  FOR  GAS. 


RIGGED  FOR  KEROSKNE. 


is  then  placed  in  the  oven  of  the  heater,  and  the  heat  applied,  the 
degree  of  which  is  determined  by  moistening  the  end  of  the  finger,  and 
applying  it  to  the  flask.  When  it  fizzles  on  contact,  as  a  sad-iron 
does  to  the  finger  of  a  washerwoman,  the  flask  is  screwed  together. 

The  point  of  a  knife  inserted  between  the  edges  of  the  flask  will 
also  determine  the  condition  of  the  celluloid  at  this  stage ;  also  by 
experience  in  screwing  down  the  flask.  More  pressure  is  applied  as 
the  celluloid  softens  or  flows,  allowing  some  little  time  to  elapse  between 
the  turning  of  the  screws,  until  the  sections  of  the  flask  are  brought 
together,  when  the  heat  is  removed  in  order  to  avoid  injuring  the  plate 


900  MECHANICS. 

by  making  it  porous.  In  the  use  of  this  apparatus,  the  edges  of  the 
flask  must  not  be  pressed  together  until  the  celluloid  is  sufficiently 
softened  to  flow;  and,  on  the  other  hand,  the  sections  of  the  flask  must 
not  be  kept  apart  too  long,  or  the  plate  will  become  hard,  from  the 
evaporation  of  the  camphor,  and  obstruct  the  proper  closing.  The 
case  is  then  removed  from  the  oven  of  the  heater  and  allowed  to  cool, 
gradually,  until  it  becomes  quite  cold. 

For  moulding  celluloid  by  dry  heat,  which  is  now  considered  to  be 
preferable  to  either  steam  or  glycerine,  the  New  Mode  Heater,  repre- 
sented by  Fig.  683,  was  the  first  apparatus  invented  which  possessed 
superior  advantages  over  the  others  used  for  such  a  purpose,  and  also  for 
vulcanized  rubber.  It  is  a  cylindrical  cast  vessel,  having  two  chambers, 
one  within  the  other,  the  inner  one  being  supported  by  piers  or  columns 
connecting  its  sides,  top,  and  bottom  with  those  of  the  outer  chamber, 
the  whole  being  made  in  one  casting.  The  outer  compartment  is  the 
steam  chamber  or  boiler,  and  incloses  the  hot-air  or  packing  chamber 
on  all  sides,  except  the  front,  where  the  walls  of  the  two  chambers 
converge  and  become  one,  for  the  purpose  of  permitting  access  to  the 
packing  chamber.  A  door,  made  of  the  same  metal  as  the  boiler, 
and  fitted  with  lead  packing,  to  make  it  steam  tight,  is  held  in  place 
by  a  bridge  secured  with  screws.  The  door  is  also  provided  with  a 
plate- glass  light  (shown  in  cut),  through  which  the  operator  can 
watch  the  progress  of  the  moulding  in  the  oven.  The  only  commu- 
nication between  the  two  chambers  is  by  means  of  a  valve  having  its 
seat  in  the  top  of  the  packing  chamber,  and  controlled  by  a  hollow 
stem  which  passes  through  the  top  of  the  machine. 

B  is  a  mercury  bath  ;  C,  thermometer ;  D,  screw  plug ;  E,  lam-nut ; 
F,  stem  of  steam  valve  ;  G,  screw  cap  ;  H,  large  screw  for  closing  the 
flask;  I,  I,  I,  smaller  screws  for  same  purpose;  K,  K,  K,  L,  nickel- 
plated  caps  for  screws  ;  O,  O,  steam  chamber. 

The  Isew  Mode  Heater,  Seabury's  and  Evans'  Vulcanizers  (Figs, 
654  and  655)  combine  in  one  apparatus  important  improvements  in  the 
means  of  working  both  celluloid  and  rubber,  that  cannot  fail  to  com- 
mend them  to  the  favor  of  the  profession. 

It  is  the  conviction  of  the  inventors,  which  is  sustained  by  the 
experience  of  many  experts  in  the  use  of  both  substances,  that  perfect 
work  in  either  can  only  be  made  in  a  dry  chamber,  and  that  where 
a  high  degree  of  heat  is  used,  such  as  is  absolutely  essential  in 
the  manipulation  of  celluloid,  the  temperature  must  be  kept  uniform 
until  the  work  is  completed,  and  must  not  be  allowed  to  change 
suddenly. 

Steam  is  used  in  these  machines  to  heat  up  the  packing  chamber 
and  investment,  but  the  chamber  itself  can  be,  and  for  certain  kinds 


CELLULOID. 


901 


of  work  must  be,  kept  absolutely  dry  after  the  moulding  commences, 
while  the  complete  control  which  the  operator  has  over  the  workings 
of  the  machine  enables  him  to  maintain  the  heat  at  any  desired  tem- 
perature.    The   hot  box  or  packing  chamber  is  nearly,  in  one,  and 

Fig   683. 


RIGGED   FOR   GAS. 

Can  be  adapted  for  Alcohol  by  substituting  the  lamp  for 
the  gas-burner. 


GAS-BLRXEB. 


ALCOHOL   LAMP. 


in  the  others  quite,  surrounded  by  the  boiler,  and  steam  may  be 
admitted  to  or  excluded  from  the  packing  chamber  at  will.  A  case 
may  be  removed  from  the  heater  and  another  one  inserted,  without 
reducing  the  temperature  or  letting  off  the  steam  from  the  boiler,  thus 
accomplishing  a  large  saving  of  time.    The  boiler  has  no  steam-packed 


902  MECHANICS. 

plunger  or  screw  to  cause  uncertainty  as  to  the  amount  of  pressure 
applied.  The  top  of  the  boiler,  in  the  case  of  the  New  Mode  Heater, 
is  cast  in  one  piece  with  the  boiler ;  the  flask  is  closed  with  a  small 
key-wrench,  by  the  thumb  and  finger,  the  screw-bolts  for  closing  the 
flask  passing  through  the  steam-chamber  in  piers  or  columns ;  a  steam- 
tight  plate-glass  door  permits  the  operator  to  examine  the  work  at  any 
time  during  the  process  of  moulding,  enabling  him  to  apply  the  proper 
pressure  at  the  right  time,  thus  reducing  the  liability  to  break  the 
cast,  investment,  or  teeth.  The  descriptions  of  the  Seabury  and 
Evans'  machines,  in  the  article  on  Vulcanite,  will  explain  their  manip- 
ulation. 

Dry  heat  has  no  injurious  effect  on  the  celluloid  material.  If  a  piece 
of  transparent  celluloid  be  passed  through  a  jet  of  steam,  the  trans- 
parency will  disappear  in  an  instant,  and  the  material  will  become 
opaque  and  lose  its  hardness.  A  piece  of  the  same  transparent 
celluloid  heated  in  a  dry  chamber  to  the  same  temperature  as  that  of 
the  jet  of  steam  is  not  afiected,  its  transparency  and  hardness  remain- 
ing unchanged.  So,  too,  a  piece  of  black  rubber  vulcanized  by  dry 
heat  is  of  a  pure  jet-black  color  when  taken  out ;  while  a  piece  of  the 
same  black  rubber  vulcanized  in  the  ordinary  method  shows  brownish 
discolorations.  These  simple  experiments  show  conclusively  that  the 
action  of  the  steam  is  the  cause  of  the  loss  of  quality.  Dr.  Campbell 
gives  the  following  directions  for  the  moulding  of  celluloid  in  his 
apparatus,  which  are  also  applicable  to  the  others : — 

To  secure  the  best  practical  results  celluloid  should  be  moulded  or 
pressed  into  the  form  desired  at  the  highest  possible  temperature  which 
will  not  burn  it.  To  prove  this  it  is  only  necessary  to  mould  a  plate 
on  a  metal  cast  at  the  lowest  temperature  at  which  it  can  be  done, 
which  is  less  than  212°,  and  another  on  the  same  cast  at  the  highest 
temperature  possible,  say  310°  or  320°,  and  lay  the  two  aside  for  a 
few  days,  when  it  will  be  found  that  the  one  moulded  at  the  lower 
temperature  will  not  fit  the  cast,  while  that  moulded  at  the  higher 
temperature  will  fit  as  well  as  when  first  made.  The  reason  is  that  the 
low  temperature  fails  to  overcome  the  tendency  of  the  plate  to  return 
to  its  original  form",  while  the  high  temperature  renders  it  so  thoroughly 
plastic  that  this  tendency  is  entirely  eradicated.  This  is  proportionally 
the  case  with  pieces  made  at  intei-mediate  temperatures ;  the  higher 
the  temperature  to  which  the  plate  is  subjected  in  moulding,  the 
more  exactly  will  it  hold  its  new  form  and  the  less  will  be  its  tend- 
ency to  warp. 

Celluloid  may  be  readily  and  safely  manipulated  in  the  New  Mode 
Heater  at  320°,  a  temperature  many  degrees  higher  than  is  deemed 
safe  in  other  machines,  and  which  accomplishes  perfectly  the  result 


CELLULOID.  903 

above  noted,  and  produces  a  plate  which  is  believed  to  be  absolutely 
unchangeable  in  color,  form  and  texture.  When  this  very  high  tem- 
perature is  employed  the  celluloid  should  be  in  the  machine  only  long 
enough  to  permit  the  closing  of  the  flask ;  for  the  reason  that  heat 
vaporizes  the  camphor — the  solvent  of  the  material.  If  too  much  of 
this  is  driven  off  before  the  flask  is  closed  it  will  be  almost  impossible 
to  mould  the  blank  to  the  desired  form.  The  sooner  the  flask  is  closed 
after  being  placed  in  the  oven,  the  more  readily  will  it  be  done,  and 
the  better  will  be  the  result. 

The  moulded  surface  of  a  piece  of  celluloid  is  much  more  durable 
than  its  interior,  and  will  retain  the  color  better.  It  is  obvious,  there- 
fore, that  this  surface  is  essential  to  the  integrity  of  the  plate,  and 
should  be  preserved  intact.  To  insure  this,  the  case  should  be  so  pre- 
pared that  the  plate,  when  taken  from  the  flask,  will  require  little  or 
no  labor  to  make  it  ready  for  use.  It  is  possible  that  some  surplus 
material  at  the  edges  may  have  to  be  trimmed  off"  and  the  edges 
smoothed,  but  the  case  is  not  properly  prepared  if  more  than  this  is 
necessary.  The  care  and  trouble  involved  in  proper  preparation  will 
really  save  time,  will  absolutely  avoid  interference  with  the  fit  by  the 
too  free  use  of  files,  sand-paper,  pumice,  etc.,  and  will  insure  a  durable 
plate  with  a  permanent  imitation  of  gum-color.  Moreover,  the  artistic 
taste  of  the  operator  may  be  exercised  before  the  plate  is  moulded 
more  readily  than  afterward. 

Parafiine  and  wax  compound  is  used  for  the  base  plate,  according  to 
directions  before  given,  and  the  teeth  arranged,  the  wax  carved  into 
the  shape  desired  by  means  of  carving  tools,  and  made  smooth.  The 
piece  is  then  invested  in  plaster,  the  usual  grooves  cut,  the  wax,  teeth 
and  tin  foil  being  removed  with  the  upper  half  of  the  flask  in  parting. 
The  wax  is  then  removed  by  means  of  boiling  water,  as  before  de- 
scribed, the  tin  foil,  No  60,  used  for  covering  the  parafiine  and  wax 
plate,  remaining  upon  the  plaster,  and  the  investment  is  now  ready  to 
be  dried  out  preparatory  to  receiving  the  celluloid. 

Drying  the  Cast  and  Investment. — To  dry  a  plaster  cast  and  invest- 
ment, and  keep  them  free  from  cracks  and  checks,  is  very  difiicult  by 
the  ordinary  means,  but  with  the  New  Mode  Heater  it  can  be  done 
so  perfectly  as  to  permit  their  use  in  casting  pure  gold  or  gold  alloys. 
There  are  two  ways  of  drying  the  investment  in  the  New  Mode 
Heater :  first,  by  raising  the  temperature  to  320°,  keeping  the  hot 
box  dry ;  second,  by  admitting  steam  to  the  hot  box.  The  former 
method  can  be  used  when  the  investment  is  placed  in  the  chamber 
before  getting  up  steam.  If  steam  is  up,  however,  either  method  may 
be  employed.  In  using  the  dry-heat  method,  open  very  slightly  the 
screw  cap  of  the  j)iston  or  valve  stem,  to  permit  the  escape  of  the  steam 


904  MECHANICS. 

generated  from  the  water  in  the  plaster,  being  careful  that  the  steam 
valve  is  firmly  seated,  as  otherwise  all  the  steam  made  in  the  boiler 
will  escape.  In  using  steam  for  drying,  admit  the  live  steam  into  the 
chamber  with  the  investment,  by  raising  the  valve  from  its  seat,  keep- 
ing the  screw  cap  closed.  The  steam  quickly  permeates  the  plaster, 
and  in  five  or  ten  minutes  the  temperature  of  the  plaster  is  high 
enough  to  convert  the  water  in  it  into  steam.  As  soon  as  the  plaster 
is  thoroughly  heated,  shut  off  the  steam  by  closing  the  valve,  and 
raise  the  screw  cap  very  slightly,  to  allow  that  in  the  chamber  to 
escape  slowly  through  the  small  aperture  at  the  side  of  the  screw.  In 
a  few  moments  the  cast  will  be  perfectly  dry,  the  steam  escaping  from 
the  chamber,  carrying  with  it  that  generated  from  the  moisture  in  the 
plaster.  Extreme  care  should  be  taken  that  the  steam  shall  escape 
very  slowly,  as  otherwise  the  plaster  may  be  blown  out  of  the  flask  into 
the  oven,  by  the  too  rapid  expansion  of  its  vaporized  moisture.  The 
completion  of  the  drying  process  is  known  by  steam  ceasing  to  be 
given  off  at  the  screw  cap,  G.  The  drying  may  be  facilitated  by 
placing  a  small  chip  of  wood  between  the  two  parts  of  the  flask  when 
it  is  put  into  the  chamber,  thus  exposing  a  larger  surface  to  the  heat 
and  allowing  the  moisture  to  escape  more  readily. 

Moulding  by  Dry  Heat. — When  the  investment  is  dried,  remove  it 
from  the  chamber  and  insert  and  carefully  adjust  the  selected  blank  ; 
replace  the  flask  in  the  oven  immediately  under  the  screws ;  see  that 
the  two  sections  are  so  placed  that  the  guide-pins  will  enter  properly 
into  the  lugs ;  open  the  screw  cap  a  turn  or  two  to  allow  the  escape  of 
the  gas  from  the  hot  box ;  turn  down  the  large  screw  until  it  bears 
lightly  upon  the  top  of  the  flask,  and  close  the  machine.  In  less  than 
five  minutes  the  material  will  be  sufficiently  softened  to  permit  the 
commencement  of  the  moulding.  The  screws  will  turn  readily  Avith 
the  thumb  and  finger  (using  the  smaller  key-wrench),  when  the  blank 
is  properly  softened.  Close  the  flask  gradually,  stopping  occasionally 
if  the  resistance  is  too  great.  Usually,  if  the  temperature  is  about 
300^,  the  flask  can  be  closed  in  ten  minutes ;  but  if  a  very  thick  blank 
is  used,  the  moulding  must  proceed  slowly ;  the  small  screws  may  be 
used  to  advantage,  and  more  time,  say  thirty  minutes,  may  be  con- 
sumed. As  soon  as  the  flask  is  closed — unless  a  lock  flask  is  used — 
the  flame  should  be  extinguished,  the  door  opened,  and  the  machine 
allowed  to  cool.  If  a  lock  flask  is  used,  it  may  be  removed  and  thor- 
oughly cooled  before  opening  it,  the  oven  being  meanwhile  ready  for 
another  case.  The  cooling  may  be  accomplished  rapidly,  if  necessary, 
by  placing  the  flask  in  water.  When  perfectly  cold,  remove  the  plate 
from  the  investment ;  it  will  be  found  enveloped  in  the  tin  foil  which 
had  been  burnished  to  the  wax  plate.    Peel  off  the  foil.    The  celluloid 


CELLULOID,  905 

will  present  a  hard,  brightly-polished  surface,  received  from  its  con- 
tact with  the  foil,  and  will  need  no  further  finishing  than  cutting  off  the 
excess  of  material  and  smoothing  down  the  edges.  The  extra  hardness 
of  the  surface  will  thus  remain  to  preserve  the  integrity  and  color  of 
the  piece.  It  is  claimed,  also,  that  the  contact  of  the  foil  renders  the 
outer  surface,  which  is  always  the  densest  portion  of  celluloid,  much 
harder. 

Imitating  Gum  Membrane. — The  plate  produced  by  the  above  method 
is  of  the  ordinary  appearance,  with  smooth,  polished  gum,  but  a  much 
more  natural,  life-like  gum  will  result  if  the  tin  foil,  after  being  bur- 
nished to  the  wax  plate  is  "  stippled."  This  is  done  by  "  dotting " 
carefully  over  its  surface  with  a  dull-pointed  instrument,  which  should 
be  held  nearly  perpendicular  to  the  surface  to  be  operated  on,  and  the 
strokes  should  be  gentle — not  hard  enough  to  perforate  the  foil.  When 
the  foil  is  removed,  after  the  case  is  moulded,  the  gums  present  an 
appearance  closely  resembling  the  natural  membrane.  The  stippling 
need  not  occupy  a  great  deal  of  time,  and  the  result  it  produces  is  a 
marked  improvement. 

Metal  Casts  and  Deep  Undercuts. — Many  dentists  who  prefer  to  use 
metal  casts  have  doubtless  found  difficulty  in  removing  the  finished 
plates  'in  cases  of  deep  undercut.  The  fact  that  a  melted  metal  cools 
from  the  surface  toward  the  centre,  supplies  an  effectual  remedy. 
When  the  metal  is  poured  into  the  sand,  allow  it  to  chill  only  about  a 
quarter  of  an  inch  on  the  outside,  and  then  pour  the  balance  out  of 
the  mould.  This  makes  a  hollow  cast  or  shell.  Fill  up  the  cavity 
with  plaster,  and  proceed  as  usual.  After  the  plate  is  moulded,  remove 
the  plaster,  place  the  edges  of  the  metal  cast  in  the  jaws  of  a  vise, 
and  crush  the  shell.  This  will  free  the  piece  without  disturbing  the 
teeth.  The  plaster  in  the  shell  also  affords  the  means  of  attaching  the 
cast  to  the  articulator. 

Repairing. — If  a  portion  of  a  plate  has  been  broken  away  and  lost, 
fit  a  piece  of  celluloid  of  the  proper  shape,  leaving  it  somewhat  larger 
than  the  space  to  be  filled.  Make  sure  that  the  surfaces  to  be  united 
are  perfectly  clean ;  even  the  perspiration  from  the  hand  may  cause  a 
dark  line.     Flask  and  mould  as  usual. 

A  crack  in  a  plate,  or  the  parts  of  a  broken  plate,  may  be  joined 
by  scraping  the  surfaces  clean,  or  washing  them  with  alcohol,  and 
moulding  a  thin  strip  of  celluloid  into  the  seam. 

The  following  method  of  repairing  small  breaks  is  suggested  by  Dr. 
M.  H.  Cryer,  and  possesses  the  merit  of  extreme  simplicity,  and  its 
results  are  in  the  highest  degree  satisfactory : — 

Remove  all  portions  of  the  broken  tooth  from  the  plate,  taking  care 
not  to  disturb  the  outlines  of  the  socket.     Select  a  tooth  of  proper  size 


906  MECHANICS. 

and  shade  to  replace  the  broken  one.  (If  the  tooth  is  numbered,  a 
considerable  part  of  the  trouble  of  selection  may  be  saved  by  taking 
the  number  of  the  mould  from  the  reverse  impression  in  the  plate,  or 
from  the  broken  pieces.)  Having  set  the  new  tooth  partly  in  its  place, 
hold  it  steadily  over  the  flame  of  an  alcohol  lamp,  carefully  guarding 
the  celluloid  from  contact  with  the  flame.  In  a  few  seconds  the  tooth 
will  begin  to  grow  warm,  and  its  heat  will  soften  the  celluloid  suffi- 
ciently to  allow  the  tooth  to  be  pressed  into  its  proper  position  with  a 
napkin.  This  will  cause  a  small  bulge  or  raised  spot  to  appear  in  the 
celluloid  opposite  the  lingual  portion  of  the  root  of  the  tooth.  Invest 
in  plaster,  in  the  deeper  section  of  the  flask,  covering  the  whole  plate 
and  the  teeth,  except  the  small  portion  of  the  celluloid  raised  in 
pressing  the  tooth  into  place.  Complete  the  investment,  part  the  flask, 
and  dry  the  case,  after  which  insert  a  piece  of  rather  thick  writing 
paper  or  heavy  tin  foil  over  the  raised  spot,  and  place  in  the  oven. 
Heat  up  to  the  usual  temperature  for  moulding  and  close  the  flask. 
When  the  case  is  cold  the  tooth  will  be  found  firmly  fixed  in  its  posi- 
tiim,  and  there  will  be  no  mark  to  show  that  the  plate  has  been 
repaired. 

In  case  a  small  portion  of  the  celluloid  is  chipped  away  from  the 
front  of  the  socket — enough  only  to  expose  the  end  of  the  root  when 
in  position — drop  a  little  wax  upon  the  vacant  spot,  after  placing  the 
tooth,  and  carve  to  the  shape  desired.  Without  removing  the  wax, 
invest  and  mould  as  before  described.  The  wax  will  pass  off"  into^the 
plaster,  and  its  place  will  be  supplied  by  the  celluloid,  of  which  there 
is  usually  enough  to  permit  the  flowing  of  the  minute  quantity  required 
without  damage. 

If  there  is  a  similar  deficiency  on  the  inside  of  the  plate,  exposing 
the  pins  of  the  tooth,  drop  wax  into  the  vacancy  and  proceed  as  before, 
except  that  in  this  case  the  wax  is  to  be  removed  when  the  investment 
is  made,  and  the  bit  of  writing  paper  or  tin  foil  is  to  be  placed  just 
below  the  pins,  instead  of  over  them,  so  as  to  force  the  flowing  of  the 
celluloid  to  cover  them. 

To  remove  a  tooth  from  a  celluloid  plate,  liold  the  outside  surface  of 
the  tooth  to  be  removed  in  the  flame  of  the  lamp  until  the  heat  softens 
the  celluloid  around  the  pins  slightly,  when  it  may  be  taken  off"  without 
trouble,  and  it  will  come  away  clean,  without  any  of  the  celluloid  ad- 
hering to  the  pins.  Do  not  move  the  plate  back  and  forth  through 
the  flame,  or  other  teeth  than  the  one  desired  may  be  loosened,  or  their 
perfect  articulation  may  be  interfered  with.  There  is  no  danger  of 
cracking  the  tooth  so  long  as  the  flame  does  not  come  in  contact  with 
the  pins. 

Fig.  684  represents  the  first  process  in  repairing  a  celluloid  plate 


CELLULOID. 


907 


from  which  a  tooth  or  block  has  been  broken.  The  plate  being  cut 
away  sufficiently  to  allow  the  new  tooth  to  be  adjusted  by  grinding,  a 
new  piece  of  celluloid  (a)  is  fitted  to  the  space.  The  new  piece  is  then 
removed  and  its  place  filled  up  with  wax.  Fig.  685  shows  the  piece 
invested  in  the  lower  section  of  the  flask,  the  space  filled  with  wax 
being  the  only  portion  visible,  the  entire  surfaces  of  the  plate  and  teeth 
being  covered.  The  upper  section  of  the  flask  is  then  adjusted  and 
filled  up  with  plaster.  When  the  flask  is  opened,  the  wax  is  removed 
and  the  new  piece  of  celluloid  returned  to  its  place,  and  upon  it  is 
placed  another  small  piece  of  celluloid,  or  a  roll  of  tin  foil,  to  produce 
pressure  upon  the  new  piece  first  added,  the  edges  of  which,  as  well  as 
those  of  the  space  into  which  it  is  fitted,  being  moistened  with  spirits 
of  camphor,  or  liquid  celluloid,  to  bring  about  union. 

Liquid  celluloid  is  made  by  dissolving  small  pieces  of  celluloid  in 


Fig.  685. 


Fig.  684. 


spirits  of  camphor.  The  piece  is  then  placed  in  the  heater  and  sub- 
jected to  the  usual  process.  Where  the  plate  is  of  considerable  thick- 
ness, a  new  tooth  or  block  may  be  added  without  new  material,  by  cut- 
ting away  as  little  as  possible  of  the  old  plate,  on  the  lingual  surface, 
and  depending  upon  the  thickness  of  celluloid  pressing  up,  after  being 
softened  in  the  heater,'  closely  to  the  new  tooth.  Loose  teeth  may  be 
tightened  in  the  same  manner,  wax  being  introduced  into  the  vacant 
space  and  removed  after  the  flasking. 

Some  object  to  the  use  of  a  solvent  in  repairing,  on  account  of  the 
liability  of  the  newly  added  material  to  become  porous.  To  cleanse 
celluloid  plates  previous  to  repairing'  they  should  be  placed  in  a  solu- 
tion of  whiting  and  water,  to  which  is  added  some  liquor  ammonia, 
and  allowed  to  remain  some  time,  when  they  are  brushed  with  soap 
and  water,  and  finally  washed  in  clean  water  and  dried. 


90S  MECHANICS. 

NEW  MODE   CONTINUOUS   GUM. 

With  reference  to  the  second  objection  to  the  use  of  rubber,  it  is 
to  be  said  that  the  perfect  reproduction  of  natural  effects  and  really 
artistic  work  cannot  be  made  with  block  teeth.  To  obtain  the  proper 
expression,  each  tooth  should  be  available  for  placing  in  any  position 
desired,  instead  of  being  arbitrarily  held  in  association  with  others,  as 
in  a  block. 

The  invention  of  the  New  Mode  machine  places  in  the  hands  of  the 
profession  the  means  for  overcoming  this  objection  by  using  plain 
teeth,  with  rubber  for  the  base,  and  celluloid,  which  is  well  suited 
for  the  purpose,  for  the  gum,  the  combination  forming  an  exquisite 
piece  of  work,  which  the  inventor  calls  the  "  New  Mode  Continuous 
Gum."  It  is  easily  the  nearest  approach  to  porcelain  continuous  gum 
that  has  been  attained  with  plastic  materials.  Its  general  adoption 
would  do  away  with  "bad  joints"  and  broken  blocks,  which  are  so 
often  a  source  of  serious  annoyance.  It  is  the  only  rubber  plate  upon 
which  a  tooth  may  be  replaced  without  re-vulcanization,  and  which 
after  the  repair  is  equal  in  strength  and  appearance  to  the  original 
piece ;  and  the  only  one  upon  which  repairs  can  be  repeated  any 
number  of  times  without  injury  to  the  original  plate.  This  same  style 
of  work  can  also  be  done  with  gold  and  with  cast-alloy  plates. 

Directions  for  Making  the  New  Mode  Continuous  Gum. — Using  teeth 
made  expressly  for  continuous-gum  or  celluloid  work,  set  them  up  in 
wax  in  the  usual  manner,  leaving  the  front  or  outside  of  the  roots 
exposed.  Cut  a  thin  strip  of  the  wax,  warm  it,  and  attach  it  to  the 
upper  edge  of  the  portion  of  the  wax  plate  representing  the  gum, 
forming  a  rim  which  extends  all  around  the  outer  margin.  Finish 
the  palatine  surface  to  the  form  desired,  invest  in  the  flask  in  the 
usual  manner,  remove  the  wax,  pack  with  rubber,  and  vulcanize. 
When  removed  from  the  flask  the  case  will  present  the  appearance 
shown  in  Fig.  687,  the  front  or  outside  of  the  roots  being  exposed 
and  the  narrow  undercut  rim  extending  all  around,  leaving  a  space 
with  retaining  grooves  between  the  teeth  for  forming  a  gum  of 
celluloid  ;  looking  very  much  as  though  the  substance  of  the  plate 
had  been  gouged  out  for  the  purpose.  The  vulcanite  plate  is  now 
completed,  with  the  teeth  firmly  attached  to  it. 

To  put  on  the  gum,  fill  up  the  groove  with  paraffine  and  wax  (this 
compound,  not  being  sticky,  does  not  adhere  to  the  instrument,  and  is 
therefore  more  easily  carved  to  the  form  desired),  until  all  the  space 
inside  the  rim,  including  the  retaining  grooves  between  the  necks  of 
the  teeth,  is  occupied.  After  the  wax  has  hardened,  which  may  be 
hastened  by  placing  in  cold  water,  carve  it  into  the  desired  form  of 
gum.    The  wax  may  be  made  very  smooth  by  throwing  upon  it  the  flame 


NEW    MODE   CONTINUOUS   GUM.  909 

of  a  spirit  lamp  with  the  aid  of  a  blowpipe,  taking  care  not  to  destroy 
the  outline  of  the  carved  gum.  Cover  the  wax  with  heavy  tin-  foil, 
burnishing  it  lightly  but  smoothly  to  the  wax. 

Invest  the  piece  again  in  the  following  manner :  Place  the  plate  in 
one  section  of  the  flask,  with  the  teeth  upward,  and  raised  at  the  front 
at  a  greater  or  less  angle,  as  may  be  necessary,  so  that  when  the 
investment  is  completed  the  upper  part  of  the  flask  may  be  removed 
without  dragging.  Imbed  in  plaster  to  the  rim,  and  pour  plaster  over 
the  palatine  surface,  covering  the  crowns,  and  taking  care  to  fill  the 
interstices  between  the  necks  of  the  teeth,  but  leaving  their  outer 
surfaces  exposed.  After  the  investment  sets,  pour  more  plaster  around 
the  inner  edge  of  the  flask  ring,  forming  a  ridge,  leaving  a  groove  or 
space  between  it  and  the  plate.  (See  Fig.  689.)  Complete  the  invest- 
ment and  remove  the  wax  from  the  groove  and  interstices  between  the 
roots  of  the  teeth  by  pouring  boiling  water  over  it.  Having  selected 
a  celluloid  blank  of  proper  size,  saw  off"  the  outer  rim  (see  Fig.  (586) ; 
warm  this  rim  of  celluloid  in  boiling  water,  and  with  the  hand  and  a 
cloth  press  it  closely  about  the  teeth,  and  hold  it  to  its  place  until 
stiff;  it  will  then  remain  there  until  the  two  parts  of  the  flask  are 
entered  upon  the  guide-pins.  Join  the  two  parts  of  the  flask  together 
and  place  the  investment  in  the  oven  of  the  machine,  having  previously 
heated  up  the  chamber.  When  the  temperature  of  280'^  is  reached, 
the  flask  may  be  closed.  As  soon  as  this  is  accomplished,  the  case  is 
ready  to  be  removed  from  the  oven  and  placed  in  a  clamp  to  cool. 

When  perfectly  cold,  remove  the  plate.  The  tin  foil  will  adhere  to 
it,  but  it  can  be  readily  removed  by  inserting  the  point  of  a  knife 
under  the  edge  and  pulling  it  ofi*,  leaving  the  surface  of  the  celluloid 
gum  as  smooth  and  polished  as  that  of  the  foil. 

A  surface  produced  by  the  above  method  presents  a  smooth,  polished 
gum,  but  if  the  tin  foil  is  "  stippled,"  as  before  described,  a  striking 
resemblance  to  the  natural  membrane  will  be  produced,  the  finished 
plate  presenting  the  appearance  shown  in  Fig.  688.  The  adjoining 
edges  of  the  celluloid  and  rubber  will  be  found  perfectly  united,  each 
preserving  its  sharp  outline. 

Dr.  D.  Genese  recommends  the  following  method  of  working  cellu- 
loid, which  will  give  a  hard,  smooth,  polished  surface  to  the  plate 
when  it  leaves  the  heater,  regulate  the  size  of  the  celluloid  blank 
before  it  is  moulded  to  the  surface  of  the  metal  die  or  cast  and  about 
the  teeth,  and  also  form  a  metal  cast,  which  is  easily  removed  from 
the  celluloid  plate  after  it  is  completed  : — 

Two  perfect  impressions  in  plaster  are  taken  of  the  mouth,  one  of 
which  is  used  to  secure  a  plaster  model,  upon  which  the  trial  plate  is 
formed,  of  wax  and  parafiine.     Upon  this  trial  plate  a  rim  of  wax  is 


910 


MECHANICS. 

Fig.  686. 


Fig.  689. 


NEW   MODE   CONTINUOUS   GUM.  911 

built,  and  the  exact  bite  secured.  In  wax,  only  the  model  of  the 
piece  desired  in  the  finished  case  is  then  formed,  which  is  attached  to 
a  metal  die,  which  has  been  obtained  by  moulding  the  plaster  model  in 
sand.  The  whole  is  then  moulded  in  sand,  and  a  zinc  and  lead  die 
and  counter-die  obtained,  by  means  of  which  a  tin  cap  (made  of  rolled 
tin.  No.  29  gauge)  is  swaged,  which  will  completely  envelope  the  wax 
model,  extend  over  the  gum  portion,  and  to  the  full  height  of  the 
finished  "  bite."  The  edge  of  the  tin  cap,  which  is  left  rough,  is  turned 
up  at  an  angle  of  about  forty-five  degrees,  so  as  to  form  a  support  for 
it  in  the  plaster,  when  it  is  invested.  The  object  of  this  cap  is  to  form 
a  metal  mould  in  which  the  celluloid  blank  can  be  shaped  to  the  form 
and  size  desired  for  the  case  in  hand.  The  modeled  wax  is  then  trans- 
ferred to  the  plaster  model,  which  is  invested  in  the  lower  half  of  the 
flask,  and  the  surface  of  the  investment  varnished  over  and  oiled,  to 
ensure  the  required  separation.  The  tin  cap  is  then  placed  over  the 
modeled  wax  surface,  and  the  upper  half  of  the  flask  filled  with 
plaster.  When  the  flask  is  separated,  the  wax  is  removed  from  the 
plaster  model,  the  tin  cap  remaining  firmly  secured  in  the  upper  half 
of  the  flask.  The  celluloid  blank  is  then  placed  in  the  tin  cap  mould, 
and  the  sections  of  the  flask  brought  together  by  being  placed  in  a 
heater.  Upon  removing  the  blank  from  the  mould,  in  the  flask,  any 
excess  of  celluloid  can  be  removed,  and  a  blank  of  a  proper  size  and 
form  secured  which  will  not  press  the  teeth  out  of  position  in  the  subse- 
quent moulding  of  the  plate.  It  is  necessary  to  secure  a  duplicate 
bite  to  mount  the  teeth,  which  is  done  on  a  metal  die  or  cast,  formed 
as  follows : — 

The  second  plaster  impression  is  removed  from  the  impression  cup, 
and  imbedded  in  a  sand  and  plaster  investment  as  deep  as  it  is  desired 
to  have  the  cast.  A  right-angle  cross,  with  arms  about  half  an  inch 
wide  at  the  upper  surface  and  tapering  to  a  sharp  edge  (V),  is  then 
made  of  plaster  mixed  with  sand,  and  placed  over  the  surface  of  the 
plaster  impression,  in  such  a  manner  as  to  bring  the  sharp  edge  almost, 
but  not  quite,  in  contact  with  the  impression  surface,  where  it  is  secured 
by  sealing  the  ends  of  the  arms  to  the  margin  of  the  impression. 
A  metal  die  or  cast  made  in  this  manner  is  divided  into  four  sections 
by  the  cross-core,  very  nearly  to  its  surface,  and  is  more  readily  re- 
moved from  the  celluloid  plate  after  it  is  moulded,  than  the  hollow  metal 
cast,  as  the  removal  of  the  plaster  core  will  permit  of  the  sections  of 
the  cast  being  bent  away  from  any  undercuts  which  may  exist.  After 
obtaining  the  form  of  metal  die  described,  the  teeth  are  mounted  upon 
a  trial  plate  formed  over  it,  and  according  to  the  duplicate  "  bite,"  and 
the  new  wax  plate  is  modeled  into  the  form  desired  for  the  finished 
celluloid  plate.    An  impression  in  sand  of  the  whole  is  again  obtained, 


912  MECHANICS. 

a  zinc  die  and  lead  counter-die  poured,  and  a  tin  cap  similar  to  the 
one  first  made  is  swaged.  This  tin  cap  forms  a  complete  metal  casing, 
and  on  flasking,  is  secured  in  the  upper  half  of  the  flask  by  means  of 
its  turned  edges.  The  case  is  then  flasked  in  the  usual  manner,  and 
on  separating  the  sections  and  removing  the  wax,  the  celluloid  blank, 
which  has  been  previously  moulded  into  form,  according  to  the  manner 
described  above,  will  be  found  well  adapted  to  the  mould.  The  case  is 
then  placed  in  one  of  the  combination  heaters,  and  moulded  at  a  temper- 
ature of  300°  which  should  never  be  exceeded ;  and  no  pressure  should 
be  applied  by  the  screws  until  this  heat  is  obtained.  The  construction 
of  partial  sets  is  more  difficult,  but  the  process  is  the  same  as  for  entire 
dentures,  a  cap  of  somewhat  lighter  tin  being  used.  By  this  process  the 
edges  only  of  the  plate,  and  a  slight  excess  of  material  about  the  necks 
of  the  teeth  require  trimming  off,  the  entire  surface  being  polished 
without  any  scraping  away,  by  first  using  fine  pumice  and  glycerine, 
and  finally  whiting  and  glycerine.  The  plate  should  be  thoroughly 
cleansed,  after  removing  it  from  the  flask,  of  all  particles  of  plaster 
that  may  adhere  to  it,  and  the  entire  manipulation  be  conducted  with 
clean  hands  and  instruments. 

A  metal  cast  somewhat  similar  to  the  one  above  described  may  be 
made  by  first  moulding  in  the  usual  manner,  and  afterwards  sawing 
all  around  the  alveolar  ridge  with  a.  fine  saw,  leaving  only  what  will 
hold  the  parts  together.  Plaster  is  poured  into  the  spaces  made  by 
the  saw,  in  order  to  render  the  cast  solid.  AVhen  the  set  is  finished 
the  plaster  is  removed  from  the  spaces,  and  pressure  made  by  a  vise 
upon  the  edges  of  the  cast,  so  as  to  crush  them  in  and  thus  free  the 
plate. 

When  the  celluloid  blanks  are  moulded  upon  plaster  surfaces,  files, 
scrapers,  and  fine  sand  or  emery  paper,  are  necessary  in  the  finishing 
process,  completing  the  operation  of  polishing  with  whiting  or  pre- 
pared chalk,  applied  by  means  of  a  soft  brush  wheel.  Camphor, 
applied  on  a  soft  cloth,  is  also  used  to  obtain  a  polish,  especially  be- 
tween the  teeth  and  other  places  beyond  the  reach  of  the  brush  wheel. 
Friction  with  the  brush  wheel,  sufficient  to  heat  the  plate,  should  be 
avoided,  on  account  of  the  danger  of  changing  the  shape  of  the  plate 
and  injuring  the  surface.  Dark  lines  on  celluloid  plates  are  often  the 
result  of  using  blanks  too  wide  for  the  case,  or  too  thin  in  the  centre, 
causing  the  celluloid  to  press  toward  the  middle  of  the  plate  and  fold 
upon  itself.  Where  the  arch  of  the  mouth  is  very  deep,  the  pressure 
by  means  of  screws  should  not  be  applied  before  the  blank  is  well 
softened  by  the  heat,  otherwise  it  may  tear  apart.  Too  little  pressure, 
or  too  little  material,  may  cause  a  porous  plate ;  also  overheating  in 
the  dry  heat  apparatus;  the  same  condition  in  steam  heating  may 


ZYLONITE.  913 

result  from  too  little  pressure  at  the  proper  time.  If  the  temperature 
of  a  celluloid  plate  is  raised  to  270°,  without  any  pressure  being 
brought  to  bear  upon  it,  the  material  becomes  puffed  up  and  is  ruined 
in  texture,  and  cannot  be  restored  by  any  subsequent  manipulation. 
Celluloid  flows  very  sluggishly,  hence  sufiicient  material  must  be 
present  to  insure  a  perfect  plate.  The  celluloid  blank  may  be  softened 
in  boiling  water  and  formed  into  any  desired  shape,  and  an  excess  at 
any  point  may  be  removed  with  a  sharp  knife.  It  should  be  remem- 
bered that  there  is  no  union  between  celluloid  and  rubber,  hence  when 
one  of  these  materials  is  added  to  the  other,  it  can  only  be  done  by 
dovetailing  or  drilling  holes.  Good,  hard-setting  plaster  should  always 
be  used  in  working  celluloid,  and  it  should  be  well  mixed  by  adding 
it  to  the  water  in  such  a  manner  that  all  is  absorbed  that  it  will  take 
up.  Care  should  also  be  taken  not  to  mix  the  plaster  too  thin,  or  to 
use  very  fine  plaster,  as  a  coarse  grade  of  strong  plaster  will  give 
better  results.  Some  are  in  the  habit  of  adding  clean  white  sand,  or 
marble  dust,  to  the  plaster.  The  following  directions  are  given  in  the 
use  of  the  New  Mode  Heater,  which  will  prove  serviceable  in  the 
working  of  celluloid  generally  : — 

Always  use  good  plaster,  and  do  not  mix  too  thin ;  always  select  a 
plate  which  nearly  fits  the  cast,  with  an  excess  in  every  part;  always 
turn  the  screws  as  soon  as  they  will  yield  to  the  thumb  and  finger,  and 
always  gently ;  always  follow  up  the  rise  in  temperature  with  increased 
pressure ;  always  give  the  material  plenty  of  time  to  flow  between  the 
turns  ;  always  increase  the  pressure  toward  the  close  of  the  moulding; 
always  reduce  the  temperature  of  the  piece  at  once  after  the  comple- 
tion of  the  moulding,  and  keep  the  plate  under  pressure  until  it  is 
stone  cold. 

ZYLONITE. 

A  modified  form  of  celluloid  has  been  recently  introduced  under  the 
name  of  zylonite,  the  working  results  of  which  appear  to  show  a  great 
difierence  in  quality.  Zylonite,  like  celluloid,  is  composed  of  pyroxylin 
and  camphor,  but  in  different  proportions,  being,  it  is  claimed,  a  chem- 
ical combination,  while  celluloid  is  a  mechanical  mixture. 

Possessing  translucency,  the  eflTect  of  zylonite  in  the  mouth  is  very 
pleasing,  and,  so  far  as  it  has  been  tested,  promises  to  be  more  durable 
than  celluloid,  without  the  tendency  to  warp,  or  to  change  color  when 
ordinary  care  is  taken  in  its  manipulation,  which  is  the  same  as  for 
celluloid.  The  zylonite  blanks  are  uniform  in  color,  and  although  this 
material  requires  the  same  amount  of  pressure  to  mould,  it  flows  with 
a  more  perfect  sharpness  of  outline  than  celluloid,  and  apparently  does 
not  disintegrate. 
58 


914  MECHANICS. 


CHAPTER  XVI. 

PORCELAI>^    TEETH. 

AS  Pharmacy  was  once  a  part  of  Medical  Practice,  and  instrument 
making  a  part  of  Surgery,  so  the  manufacture  of  Porcelain  teeth 
■was  at  one  time  confined  to  the  dental  laboratory.  Until  within  the 
past  thirty  years,  a  practical  knowledge  of  the  Dento -ceramic  art  was 
considered  an  essential  part  of  dental  education.  Galen  compounded 
his  celebrated  Theriaca  for  two  Roman  Emperors ;  Pare  and  Wise- 
man made  many  of  their  surgical  instruments  ;  and  necessity  has  com- 
pelled physicians  and  surgeons  in  all  ages  to  imitate  these  examples. 
But  the  medical  and  surgical  world  have  for  many  years  committed 
the  manufacture  of  drugs  and  instruments  to  those  who,  by  making  it 
a  special  art,  can  produce  far  better  results. 

The  time  has  fully  come  when  Dentistry  should  do  the  same  with 
porcelain  work,  for  two  sufficient  reasons  :  1.  Manufacturers  now  offer 
to  the  profession  porcelain  teeth  in  such  variety  of  beautiful  forms, 
that  not  one  dentist  in  a  thousand  could  equal  them.  2.  Moderate 
proficiency  in  block  carving  requires  such  an  amount  of  preparatory 
training  and  of  continuous  experience,  that  the  dentist's  education  and 
practice  must  suffer,  in  the  line  of  important  duties  which  cannot  thus 
be  delegated  to  others.  Hence  nearly  if  not  quite  all  of  the  most 
skillful  block  carvers  engaged  in  the  general  practice  of  dentistry 
have,  since  the  year  1850,  one  after  another,  given  up  this  art,  which 
it  cost  them  so  much  to  acquire.  For  these  reasons,  and  also  because 
the  management  of  a  porcelain  furnace  cannot  be  taught  in  books,  we 
shall  not  attempt  in  this  chapter  to  give  a  full  and  didactic  exposition 
of  the  manner  of  making  porcelain  block  or  single  teeth.  Those  who 
desire  such  knowledge,  with  a  view  to  making  it  a  specialty,  require 
that  which  it  no  longer  comes  within  the  scope  of  a  work  on  the 
"  Principles  and  Practice  of  Dentistry  "  to  teach. 

There  is,  however,  on  the  part  of  all  students,  and  probably  of  most 
practitioners,  a  desire  to  know  the  composition  of  dental  porcelain,  and 
to  have  some  idea  of  the  manner  in  which  a  few  earthy  materials  and 
metallic  oxides  are  made  to  assume  such  beautifiil  forms.  Some 
knowledge  of  the  component  parts  of  porcelain  is  essential  to  a  correct 
understanding  of  the  necessity  for  their  admixture,  as  well  as  of  the 
effects  thus  produced. 


PORCELAIN  TEETH.  915 

PORCELAIN  MATERIALS. 

The  infusible  earths  Silica  and  Alumina,  and  the  fusible  alkalies 
Potassa  and  Soda,  form  the  bulk  of  all  porcelain.  Certain  metallic 
oxides,  in  small  quantity,  give  color,  and  some  varieties  of  pottery  are 
modified  by  small  proportions  of  Lime  and  Magnesia.  Dental  porce- 
lain is  made  from  the  purest  compounds  of  silica,  alumina,  and  potassa, 
colored  by  metallic  Gold  and  Platina,  and  by  the  oxides  of  Gold* 
Titanium,  Manganese,  Cobalt  and  Uranium. 

SILICA. 

Silica  (quartz,  silex,  silicic  acid)  is,  next  to  Oxygen,  the  most  univer- 
sally diffused  substance  in  nature,  constituting  fifty  per  cent,  of  all  rocks. 
Granite,  granitic  rocks,  sandstones  and  sand  contain  not  less  than  three- 
fourths  silica ;  mica  schist,  clay  sla»te  and  clay,  not  less  than  two-thirds ; 
trap  rocks  and  lava,  one-half.  Silica  is  to  the  mineral  kingdom  what 
carbon  is  to  the  vegetable — the  element  of  stability.  In  its  purest 
forms  (rock  crystal,  Brazilian  pebbles,  or  crystals  of  quartz),  it  is  free 
from  discoloration  by  iron  or  other  oxides,  it  is  absolutely  infusible, 
and  is  insoluble  in  water  ;  this  is  the  kind  selected  for  dental  porcelain, 
but  for  other  varieties  of  porcelain,  flint  is  commonly  used.  It  forms 
silicates  with  alumina,  magnesia,  lime,  potassa  and  soda ;  the  most 
important  of  which,  in  this  connection,  are  the  silicates  of  alumina 
and  potassa.  Silica,  as  found  in  feldspar  and  kaolin,  is  partly  pure 
silica,  partly  the  silicate  of  alumina.  Now  the  "  behavior"  in  the  fur- 
nace of  silica'  and  the  silicate  of  alumina  is  different ;  hence,  chemical 
analysis  can  estimate  only  the  relative  purity  of  these  substances  ; 
experiment  alone  can  determine  the  proportions  of  each  necessary  for 
the  development  of  any  required  property  in  porcelain. 

FELDSPAR. 

Next  to  silica,  alumina  (oxide  of  aluminum)  is  the  most  universally 
diffused  of  all  minerals ;  but,  unlike  silica,  it  is  rarely  found  uncom- 
bined.  "Hie  gem  Sapphire  is  pure  crystallized  alumina,  and  is  the  next 
hardest  mineral  to  the  diamond ;  a  less  pure  form  is  well  known  in 
dentistry,  as  emery  or  corundum  ;  some  specimens  of  which  seem,  under 
the  lens,  to  be  a  collection  of  minute  crystals  of  dark-colored  sapphire. 
For  porcelain  manufacture,  alumina  is  never  used  in  its  pure  state, 
but  in  its  natural  combinations  with  silica,  lime,  potassa  and  soda. 
For  dental  porcelain  only  two  of  these  are  used — Feldspar  (known  to 
the  Chinese  as  Pe-tun-tse)  and  Kaolin.  Feldspar  is  a  silicate  of  alumina 
and  potassa,  containing  a  little  lime  and  a  trace  of  iron.  A  less  com- 
mon variety  of  spar  contains  soda  in  place  of  potassa ;  it  makes  a  soft 
porcelain,  fusible  at  lower  heat  than  the  potash  spar.    Lime  feldspar  is 


916  MECHANICS. 

used  in  some  kinds  of  pottery,  but  for  dental  purposes  potash  feldspar 
is  the  only  variety.  It  is  an  abundant  mineral,  and  is  often  found  in 
large  masses ;  the  purest  varieties  alone  are  used  for  dental  porcelain. 
Delaware  and  Pennsylvania  spars  are  most  esteemed  by  American 
manufacturers.  Its  most  extensive  dissemination,  however,  is  as  one 
of  the  components  of  granite  and  granitic  rocks,  by  disintegration  of 
the  feldspathic  constituents  of  which  large  beds  of  porcelain  clay  are 
formed,  as  found  in  China  and  Japan,  England,  Germany  and  France, 
and  also  in  the  United  States. 

Kaolin. — Ka-o-lin  (the  Chinese  word  for  clay)  is  the  purest  of 
these  mixtures  of  silica  and  silicate  of  alumina,  prepared  in  Nature's 
laboratory,  for  the  manufacture  of  porcelain.  Pipe  clay,  potter's  clay, 
blue  clay,  fire  clay,  and  Cornish  stone  are  similar  in  composition,  but 
only  the  purest  kaolin  is  used  for  dental  porcelain.  It  contains  nine 
parts  of  silica  and  eight  parts  alumina;  whereas  spar  has  nine  parts 
silica  and  only  two  parts  alumina ;  also  spar  is  made  fusible  by  its 
silicate  of  potassa — kaolin  has  none.  Kaolin  is,  therefore,  feldspar, 
deprived  of  its  soluble  silicate  of  potassa  (or  soda)  which  has  been 
washed  out  during  the  disintegration  of  the  feldspathic  rocks.  It  is 
soft  and  unctuous,  and  is  highly  plastic ;  pulverized  spar,  on  the 
contrary,  is  granular  or  powdery,  and  is  moulded  with  difficulty. 
Kaolin,  like  silex,  is  infusible ;  under  intense  and  continued  heat  it 
shrinks  greatly,  and  becomes  extremely  hard,  but  it  is  always  porous 
and  absorbent.  Silex  lessens  the  contraction  of  kaolin,  spar  gives  it 
fusibility ;  both  diminish  its  absorbent  quality,  so  objectionable  in 
any  material  that  is  to  be  worn  in  the  mouth. 

Stone  ware,  China  Avare,  Wedgewood  ware,  Parian  porcelain,  and 
Dental  porcelain  vary  in  their  properties  because  of  the  different  pro- 
portions in  which  kaolin  and  feldspar  are  combined,  also  in  the  kind 
of  flux  used.  For  instance,  the  Parian  statuettes  have  kaolin  and  spar 
in  equal  proportions,  with  about  half  as  much  of  a  flux,  made  of  spar, 
quartz  and  potash.  Dental  porcelain,  demanding  less  heat,  less  shrink- 
age and  a  more  translucent  appearance,  has  a  very  much  greater  pro- 
portion of  spar.  It  has  required  a  very  extended  series  of  experiments 
to  combine  silica,  alumina  and  potassa  in  correct  proportions,  and  to 
know  just  which  of  Nature's  compounds  it  is  best  to  use,  in  order  to 
harmonize  the  requisites  of  strength  and  beauty,  so  essential  to  the 
character  of  a  porcelain  tooth. 

COLORING   MATERIALS. 

The  foregoing  materials  give  a  pure  white  porcelain  of  greater  or 
less  translucency.  It  is  now  required  to  find  substances  which  will,  in 
the  strong  heat  of  the  furnace,  yield  indestructible  colors,  by  skillful 


PORCELAIN  TEETH.  917 

combination  of  which  the  porcelain  may  imitate  the  almost  endless 
varieties  of  tint  in  the  natural  teeth  and  gum.  Of  these  there  are 
three  principal  colors  and  three  subordinate  ones. 

Titanium. — The  purest  varieties  of  the  oxide  of  titanium  are  se- 
lected ;  it  is  found  as  a  mineral  in  various  localities  throughout  the 
United  States.  The  crystals  are  red  dish- brown,  and  have  a  bright  me- 
tallic lustre;  they  give,  when  ground,  a  beautiful  yellow,  or  yellowish- 
brown  color.  It  is  used  in  the  coloring  of  all  hocly,  and  is  the  basis  of 
color  for  the  class  of  yellowish  enamels. 

Platinum. — This  metal,  precipitated  from  its  solution  in  aqua- 
regia,  then  washed  and  dried,  is  known  as  platina  sponge.  It  gives  a 
gray-blue  color,  and  is  the  basis  of  color  for  the  class  of  grayish-blue 
enamels. 

Gold. — Gold  precipitate  is  used  to  give  life  and  animation  to  the 
tooth,  producing  often  a  very  remarkable  effect.  The  oxide  of  gold, 
known  as  Purple  of  Cassius,  and  generally  considered  to  be  a  mixed 
oxide  of  gold  and  tin,  is  used  to  impart  the  well-known  red  color  of 
the  artificial  gum ;  no  less  costly  substitute  has  ever  been  found  for 
this  purpose. 

Oxide  of  Manganese  gives  a  purplish  color,  and  is  used  occasionally 
for  some  shades  of  tooth,  but  not  of  gum.  Oxide  of  Cobalt  gives  a 
bright  blue  color.  If  wrapped  in  best  blue  paper,  and  burned  in  a 
covered  crucible,  it  is  called  the  ashes  of  cobalt,  and  is  thought  to 
give  a  more  desirable  tint  to  the  enamel  than  the  simple  oxide.  Oxide 
of  Uranium  is  used  in  its  mineral  form,  and  gives  a  greenish-yellow 
color ;  while  a  lemon-yellow  color  may  be  given  by  the  oxide  of  silver ; 
but  this  is  a  fugitive  color  at  high  temperatures. 

These  colors,  singly  and  in  combination  with  each  other,  produce  a 
great  variety  of  colors  or  shades.  Thus,  say  forty  shades  of  body 
color  are  made  by  using  these  materials  in  different  quantities  and  in 
different  combinations;  also  a  like  number  of  enamel  colors.  Then, 
starting  with  the  lightest  shade  of  body,  forty  different  grades  may  be 
produced,  by  using  a  different  point  enamel ;  so  of  each  of  the  forty 
shades  of  body,  making,  if  required,  sixteen  hundred  variations  of 
shade. 

The  following  formulas  will  suffice  to  give  a  correct  idea  of  the  pro- 
portions in  which  the  preceding  materials  are  combined,  to  give  the 
Body  and  Enamel  of  porcelain  teeth,  single  or  in  sections : — 

.    BODY.  ENAMEL. 

Feldspar 12  oz.  Feldspar 3  oz. 

Quartz 2  oz.  Sponge  Platina 1  to  4  grs. 

Kaolin 15  dwts.  Flux 3  dwts. 

Titanium 24  to  48  grs. 


918  MECHANICS. 

The  Flux  here  mentioned  is  made  by  fusing  four  ounces  of  finely 
ground  quartz  with  Glass  of  Borax  and  Sal  Tartar,  each  one  ounce ; 
it  forms  a  transparent  glass.  The  following  formulas  show  the  prepara- 
tion of  Gum  Enamel : — 

GUM    FRIT.  GUM    EXAMEL. 

Oxide  of  Gold 10  grs.         Gum  Frit 1  oz. 

Feldspar 1  oz.  Feldspar 3  oz. 

Flux 8  dwts. 

The  titanium,  platina  and  oxide  of  gold  must,  in  these  recipes,  of 
course,  be  modified  by  mixture  with  other  colors,  to  produce  the  requi- 
site varieties  of  shade.  We  shall  now  briefly  describe  the  processes 
by  which  the  porcelain  teeth  and  sections  sold  to  the  profession  are 
manufactured. 

PROCESS    OF   MANUFACTL'PvE. 

The  silex  and  feldspar,  in  their  crude  state,  are  first  submitted  to 
a  red  heat,  then  suddenly  thrown  into  cold  water.  This  is  called 
"  Calcining,"  and  the  effect  is  to  render  them  more  easily  broken  and 
pulverized.  All  impurities  having  been  carefully  removed,  they  are 
crushed  between  flint  stones ;  when  fine  enough,  they  are  put  into  a 
mill,  formed  of  burr  millstone,  with  chasers  of  the  same  material. 
They  are  ground  in  water,  then  floated  off,  and  allowed  to  settle.  The 
water  is  then  drawn  off  or  evaporated  ;  the  silex  and  spar,  dried  and 
sifted,  are  then  ready  for  use.  The  kaolin,  having  been  already  pul- 
verized in  iN^ature's  laboratory,  is  prepared  by  washing  until  perfectly 
free  from  impurities,  and  when  dry  is  ready  for  use.  The  flux  and 
frit  are  coarsely  ground,  but  the  coloring  materials  are  reduced  to  an 
mpalpable  powder.  All  these  porcelain  materials  are  combined  in 
proper  proportions  to  form  the  body  and  the  enamel,  then  mixed  with 
water  and  worked  into  masses  resembling  putty.  When,  however,  the 
method  of  biscuiting  is  adopted,  the  enamels  are  mixed  in  a  much 
thinner  state  than  the  body. 

The  unbaked  porcelain  masses  are  now  ready  for  the  moulding  room. 
The  moulds  in  which  single  teeth  or  sections  are  formed  are  made  of 
brass,  and  are  in  two  pieces — one-half  of  the  tooth  being  represented 
on  either  side.  The  precise  shapes  desired  are  carved  out  with  great 
care ;  holes  are  drilled  to  receive  the  platina  pins  in  each  tooth  ;  when 
the  two  halves  are  fitted  accurately  together,  with  guiding  pins  for 
exact  closure,  the  mould  is  ready  for  use.  The  brass  matrix  must  be 
made  about  one-fifth  larger  than  the  size  desired,  to  allow  for  shrinkage 
of  the  porcelain  paste.  After  greasing  the  moulds,  the  fii'st  operation 
is,  by  means  of  small  tweezers,  to  place  the  platina  pins  in  the  holes 
made  for  them  ;  fthere  are  many  sizes  of  these  pins,  differing  in  length 


PORCELAIN   TEETH. 


919 


and  thickness,  to  suit  the  different  sizes  of  the  teeth).  As  no  piece  of 
mechanism  can  be  stronger  than  its  weakest  point,  there  should  always 
be  such  a  relation  between  the  tooth  substance  and  the  pins,  as  to 
shape,  size,  and  angle  of  insertion,  that  one  will  be  as  strong  as  the 
other,  and  both  sufficient  for  all  legitimate  uses.  The  strength  of  pin, 
without  loss  of  strength  in  the  tooth,  characterizes  a  recent  and  valuable 
improvement  made  by  the  late  Dr.  S.  S.  White,  and  known  as  the  "  foot- 
shaped  pin,"  illustrated  in  Fig.  690.     The  thickest  part  of  this  pin  is 


Fig.  690. 


t=^ 


at  the  angle,  or  heel ;  the  point,  or  toe,  runs  upward  into  the  thick  part 
of  the  tooth,  giving  additional  security  against  its  being  drawn  out. 
The  insertion  of  the  pin  at  an  upward  angle  beds  it  in  the  strongest 
portion  of  the  tooth  material ;  thus  any  weakening  of  the  thin  portion 
of  the  tooth  is  avoided,  as  when  the  headed  pin  is  inserted  in  a  straight 
line;  also,  the  greatest  amount  of  material  is  found  where  the  greatest 
strain  is  brought  to  bear  upon  it.  The  force  of  mastication  is  exerted 
outward   and   toward   the  necks  of  the   teeth ;  thus  the  shape  and 


Fig.  691. 


direction  of  this  pin  are  best  calculated  directly  to  oppose  it.  It  will 
also  be  noticed  that  its  direction  and  unusual  length  of  insertion 
permit  a  close  grinding  of  the  tooth,  which  would  cause  the  usual 
short  and  horizontal  pin  very  soon  to  break  away  from  the  porcelain. 
The  double-headed  pin,  a  previous  patented  invention  of  Dr.  White, 
was  a  very  great  improvement  in  the  shape  of  tooth  pins ;  but  it 
has  been  superseded  by  this  new  "  foot-shaped  pin." 

Fig.  691  represents  both  plain  and  sectional  gum  teeth  with  the 


920  MECHANICS. 

lateral  or  cross  pins,  devised  by  Dr.  C.  H.  Land,  which,  it  is  claimed, 
give  greater  strength  to  the  completed  denture  than  when  teeth  with 
the  ordinary  pins  are  used.  For  continuous-gum  teeth,  a  complete 
arch  is  formed  by  twisting  or  soldering  the  pins  together,  thus  lessen- 
ing the  strain  upon  any  single  tooth,  and  allowing  a  much  lighter 
plate  to  be  used. 

The  pins  being  properly  adjusted,  the  enamels  for  the  tooth  and  the 
gum  are  placed  in  the  moulds,  by  means  of  a  small  steel  spatula,  care- 
fully placing  them  in  the  exact  position  and  quantity  required  ;  the 
body  is  placed  in  them  in  lumps  corresponding  to  the  size  of  the 
teeth ;  the  top  of  the  mould  is  then  put  on,  and  the  matrix  placed 
under  a  press,  which  compacts  each  separate  mass.  They  are  then 
dried  by  a  slow  heat.  When  perfectly  dry,  the  top  is  removed,  and 
the  teeth  will  now  drop  out.  In  this  state  they  are  extremely  tender, 
owing  to  the  large  percentage  of  feldspar,  and  require  very  careful 
handling. 

They  are  now  sent  to  the  trimmers'  room,  where  each  tooth  is  care- 
fully inspected,  and  all  imperfections  removed  or  filled  up  ;  the  spare 
edges  left  by  the  union  of  the  two  sides  of  the  mould  are  smoothly 
filed,  and  the  arch  of  the  gum  over  each  tooth  made  rounding  and 
true  with  a  small  pointed  instrument.  They  are  then  placed  on  beds 
of  coarse  quartz  sand,  on  trays  or  slides  made  of  fire-clay,  and  are 
ready  for  the  furnace.  Formerly,  there  was  another  process,  called 
crucing,  or  biscuiting,  which  was  universally  practiced,  and  is  still 
used  in  some  factories ;  it  is  also  used  in  the  making  of  blocks  carved 
to  order.  It  consists  in  submitting  the  teeth,  after  moulding,  to  a  heat 
sufficient  to  harden  them  so  they  can  be  cut  or  filed  like  chalk,  and 
what  is  called  an  outside  enamel  is  then  applied  with  a  camel's-hair 
brush  ;  but  it  has  been  found  that  the  composition  of  the  tooth  is 
injuriously  affected  by  this  partial  burning,  subsequent  cooling,  enam- 
eling and  reburning.  This  process  is  unavoidable  when  the  blocks 
are  carved  by  hand  for  special  cases ;  but  whenever  they  can  be  made 
in  a  matrix,  the  tooth  is  better  and  stronger  when  it  is  enameled  in 
the  mould,  and  finished  in  a  single  firing. 

The  furnace  is  built  substantially  on  the  principle  of  the  dentists' 
furnace  (Fig.  623),  differing  chiefly  in  size.  The  trays  holding  the 
teeth  are  placed  in  the  mufile,  and  are  thus  protected  against  injury 
from  the  gases  of  the  fuel.  There  is  no  rule  which  can  be  given  to 
determine  the  exact  amount  of  time  the  teeth  must  remain  in  the 
furnace ;  the  practiced  eye  of  the  burner  must  determine,  from  the 
appearance  of  the  teeth,  when  the  firing  is  completed.  If  taken  out 
before  they  are  done,  the  enamel  will  craze,  or  crack,  in  cooling ;  if  a 
little  too  much  done,  the  surface  will  be  too  glassy,  and  the  body  will 


PORCELAIN   TEETH.  921 

not  be  strong.  When  cool,  the  teeth  are  removed  from  the  slides, 
placed  upon  wax  cards,  and  are  then  ready  for  the  dentist. 

The  vast  variety  in  shape,  size,  color,  etc.,  of  the  teeth  thus  made, 
gives  opportunity  for  the  selection  of  forms  suitable  to  nearly  every 
case  which  presents  itself  to  the  practitioner.  The  assortment  must  of 
necessity  be  very  large  and  varied,  to  meet  the  wants  of  the  operator; 
in  fact,  the  manufacturer  has  shown  a  better  appreciation  of  the 
aesthetic  requirements  of  the  dental  art  than  the  practitioner.  While 
the  work  of  the  latter  too  often  exhibits  an  unmeaning  monotony,  the 
former  has  made  provision  for  even  the  extreme  cases  which  are  some- 
times met  with ;  he  has  also  given  a  beautiful  series  of  those  various 
deviations  from  a  uniform  regularity  which  are  so  common  in  natural 
dentures.  In  some  mouths  these  seem  to  be  imperatively  demanded, 
to  restore  the  familiar  expression ;  while  in  any  mouth,  the  use  of 
some  one  or  other  of  them  would  go  far  to  disarm  that  suspicion  of 
artificiality,  detection  of  which  is  mortifying  to  most  patients. 

Porcelain  is  a  material  in  which  the  beauty  of  the  result  well  repays 
the  highest  exercise  of  Art.  It  has  been  for  centuries  a  favorite  ma- 
terial for  expressing  the  Poetry  of  Form.  The  famous  Etruscan  vases 
of  antiquity,  the  exquisite  gems  of  the  Majolica  of  the  sixteenth  cen- 
tury, the  marvelous  works  of  Bernard  Palissy,  the  prince  of  potters, 
the  beautiful  productions  of  the  Sevres  and  Dresden  manufactories, 
the  well-known  charming  designs  of  the  Wedgewood  Avare,  and  the 
still  more  recent  Parian  statuettes,  may  be  named  in  proof  of  the  fit- 
ness of  porcelain  to  embody  the  conceptions  of  Genius.  Dental  porce- 
lain is  worthy  of  such  associations ;  not  only  like  them  does  it  delight 
the  eye,  and  give  evidence  of  high  aesthetic  cultivation,  but  it  adds  to 
beauty  the  charm  of  usefulness.  It  is  customary  to  attribute  the  rapid 
growth  of  Dental  Art,  since  1840,  to  its  Associations,  Colleges,  Jour- 
nals, and  its  didactic  Literature — and  with  much  truth.  But  to 
porcelain  it  owes  its  very  existence,  as  an  aesthetic  art,  and  the  larger 
part  of  its  extent  and  utility  as  a  prosthetic  art.  It  was  altogether 
impossible  for  perishable  human  teeth,  or  their  wretched  imitations  in 
ivory,  to  offer  such  tempting  fac-similes  of  nature  as  we  meet  in  porce- 
lain. By  thus  creating  that  enormously  increased  demand  for  dental 
service  which  has  been  the  chief  cause  of  the  rapid  development  of  its 
resources,  it  has  made  the  dental  profession  its  debtor  to  a  greater  ex- 
tent than  any  other  single  influence.  The  depot  not  only  renders  ser- 
vice by  the  superior  excellence  of  the  surgical  instruments  and  pros- 
thetic materials  which  it  supplies,  but  it  directly  benefits  the  science  and 
art  of  dentistry,  by  releasing  the  practitioner  from  manufacturing  toil, 
and  giving  time  for  the  acquirement  of  increased  knowledge  and  skill. 
Thus,  if  the  time  heretofore  given  to  block  making  were  devoted  to 


922  MECHANICS. 

the  study  of  dental  aesthetics,  patients  would  have  the  benefit  of  an 
artistic  selection  from  a  far  larger  variety  of  porcelain  dentures  than 
could  otherwise  be  possibly  made.  The  illustrations  of  this  chapter 
can  but  imperfectly  convey  an  idea  of  the  beauty  and  expression  of 
the  originals ;  they  will,  however,  assist  the  student  in  his  study  of 
those  principles  which  guide  in  the  selection  and  arrangement  of  teeth ; 
they  may  serve  also  to  awaken  practitioners  to  the  extent  of  the  pres- 
ent resources  of  Ceramic  dentistry,  and  to  the  importance  of  aesthetic 
culture  in  order  properly  to  make  full  use  of  the  same. 

The  improvements  in  the  Dento-ceramie  Art  have  sprung  from  a 
careful  inquiry  into  the  essential  characteristics  which  artistically 
formed  porcelain  teeth  should  possess.  Among  these  are  (1)  Natural- 
ness; under  which  term  are  included  shape,  color,  and  a  vital  appear- 
ance; the  last  depending  upon  the  precise  amount  of  translucency,  the 
texture  of  the  surface,  and  the  nice  blending  of  the  colors  of  the  body 
and   enamel — an  appearance  which   should   be   maintained   as  well 

Fig.  692. 


under  artificial  as  under  solar  light.  Many  teeth  which  will  bear  in- 
spection reasonably  well  in  daylight,  have  a  very  unnatural  and  arti- 
ficial appearance  when  exposed,  in  the  mouth,  to  a  light  under  which 
the  wearer  may  be  most  anxious  to  excite  admiration.  (2.)  Shape  ; 
which  includes  a  preservation  of  the  distinctive  characteristics  of  each 
tooth,  securing  the  instant  recognition  of  its  position  in  the  dental  arch. 
There  must  be  some  defect  or  inaccuracy  of  form  if,  out  of  the  twenty- 
eight  teeth  of  a  set,  in  unassorted  confusion,  an  experienced  eye  can- 
not tell  the  place  of  each ;  for  every  tooth  has  its  distinctive  contour. 
Not  only  should  each  tooth  possess  the  individuality  which  belongs  to 
it,  but  it  should  also  indicate  the  character  of  its  relation  to  its  com- 
panions on  either  side,  and  to  its  antagonist.  The  eye  trained  to 
observe  nature  should  not  be  offended  by  the  recognition  of  any  iu- 
harmony ;  should  not  find  a  second  bicuspid  or  molar  in  place  of  a  first, 
or  incisors  undistinguishable  from  each  other,  or  an  upper  tooth  in 
place  of  its  corresponding  lower  one ;  nor  should  it  detect  in  the  midst 


PORCELAIN   TEETH. 


923 


of  one  style  of  denture  some  incisor  or  canine  characteristic  of  another. 
Figs.  692  and  693  exhibit  very  strikingly  the  marked  peculiarities  of 
each  one  of  the  twenty-eight  teeth  of  an  artistically  designed  artificial 
set ;  while  these  and  subsequent  illustrations  demonstrate  how  possible 
it  is  for  modern  dentistry  to  adapt  its  work  to  the  great  varieties  of 
facial  expression.  Probably  every  reader  has  more  than  once  turned 
at  the  sound  of  a  familiar  voice,  to  see  a  face  strangely  resembling  the 
looked-for  friend.  This  correspondence  between  voice  and  face,  often 
so  startling,  is  only  another  one  of  those  links  between  external   and 

Fig.  693. 


internal   conformation,  which   makes  the  study  of  aesthetic  anatomy 
essential  to  the  success  of  the  dental  mechanician. 

The  great  law  of  correspondence,  which  enabled  Cuvier  to  build  up 
the  entire  skeleton  from  a  single  bone,  makes  us  associate  the  idea  of 
intellect  with  certain  forms  of  forehead,  and  of  character  with  certain 
forms  of  mouth,  nose,  and  chin ;  it  is  the  same  law  which  permits  us  to 
infer  from  what  remains,  the  expression  of  what  is  lost.  Age,  sex,  temper- 
ament, and  complexion ;  also  many  physical,  mental,  and  even  moral 
peculiarities,  are  suggested  to  the  acute  observer  by  certain  character- 


924 


MECHANICS. 


istics  of  the  dental  organs.  The  artist  who  seeks  to  restore  harmony  in 
the  facial  expression  should  be  skilled  in  the  observance  of  these  varied 
manifestations ;  such  skill  is  demanded  alike  in  the  manufacture  and 
in  the  application  of  artificial  dentures. 

In  addition  to  these  sesthetic  qualities,  porcelain  teeth  should  possess 
(3)  Strength  adequate  to  the  legitimate  use  for  which  they  are  intended  ; 
this  strength  should  come  from  the  quality  of  their  composition,  the 
skillful  distribution  of  bulk  to  parts  most  requiring  it,  and  from  the 
due  form,  position  and  proportion  of  the  pins,  rather  than  from  any 
increase  in  bulk  and  weight  beyond  that  of  the  natural  organs.  They 
should  possess  also,  by  reason  of  their  conformation,  (4)  Adaptability 
to  the  various  irregularities  caused  by  unequal  absorption  of  the 
alveolar  ridge,  so  that  when  judiciously  selected  they  shall  require 


Fig.  694. 


Fig.  695. 


little  labor  to  adapt  and  antagonize  them.  Special  provision  should 
be  made  for  the  results  of  extreme  or  very  irregular  absorption,  or  for 
the  loss,  by  disease  or  otherwise,  of  parts  of  the  maxillary  ridge,  so 
that  in  such  cases  the  teeth  can  readily  be  made  to  articulate  and 
afford  comfort  to  the  wearer,  assisting  in  speech  and  mastication,  and 
yet  not  presenting  any  incongruous  appearance. 

There  are,  moreover,  special  modifications  demanded  by  many  other 
conditions  ;  as,  for  instance,  in  cases  having  a  very  short  articulation, 
requiring  the  pins  to  be  set  in  a  recess,  near  the  crowns  of  the  teeth,  thus 
bringing  the  greatest  resistance  where  there  is  the  greatest  strain  in 
mastication ;  as  is  well  shown  in  Fig.  695.     In  both  these  blocks  the 


PORCELAIN   TEETH. 


925 


full  external  size  of  tooth  is  given,  and  its  characteristic  form  and  the 
expression  of  interdental  gum  preserved;  this  could  not  be  done  with 
the  usual  form  of  blocks,  ground  down  to  suit  such  cases.  In  Fig.  694 
we  have  front  blocks  for  mouths  where  a  shoulder  is  required  to 
antagonize  with  the  lower  front  teeth,  when  there  are  no  back  teeth 
remaining.  "Where  early  contraction  and  protrusion  of  the  upper 
maxillary  arch  has  caused  it  to  have  a  sharply  curved  projection, 
bringing  the  closure  of  the  lower  teeth  much  behind  the  upper  ridge 
at  the  central  incisors,  or  where  absorption  above  has  left  a  ridge 
prominent  at  its  lower  edge,  or  margin  of  the  gum,  it  becomes  neces- 
sary to  give  a  peculiar  twisted  form  to  the  front  blocks.  In  Fig.  696. 
the  first  two  blocks  are  for  a  pointed  arch,  accompauied  in  the  second 
by  a  crowded  denture,  so  often  seen  in  such  cases.     It  is  impossible  to 

Fig.  696. 


adapt  blocks  of  ordinary  form  to  such  cases  without  destroying  their 
true  expression  at  one  or  other  of  the  joints  ;  in  fact,  much  of  both 
gum  and  tooth  is  often  sacrificed  to  get  correct  articulation.  The 
third  blocks  are  shaded,  with  a  view  to  show  the  fullness  of  gum  at 
the  centrals,  and  its  falling  back  over  the  canines ;  this  is  also  shown 
in  the  sectional  views  of  the  first  and  third  blocks. 

For  cases  in  which  the  lower  jaw  closes  more  or  less  in  advance  of 
the  upper  maxillary  ridge,  a  large  gum  is  often  necessary,  as  in  Fig. 
698 ;  but  such  mouths  require  a  peculiar  form  of  block,  if  the  lower 
jaw  has  much  projection.  Where  such  a  prominence  of  the  gum 
exists,  from  want  of  exterior  absorption  or  the  previous  wearing  of  a 
plate,  as  to  require  the  teeth  to  be  set  directly  upon  the  ridge,  there 
should  be  no  artificial  gum  between  it  and  the  lip.     When  the  molar 


926 


MECHANICS. 


block  of  lower  sets  extends  to  where  the  ramus  of  the  jaw  begins  to 
rise,  a  peculiar  ploughshare  curve  of  the  base  is  required ;  such  that, 
while  the  gum  of  the  second  bicuspid  lies  on  the  outside  of  the  ridge, 
the  gum  of  the  second  molar  may  lie  partly  upon  the  ridge,  so  as  to 
give  more  perfect  antagonism  with  the  upper  molars.     The  molar  and 

Fig.  697. 


bicuspid  teeth  from  which  Fig.  697  was  drawn  are  also  marked  by 
a  characteristic  curve  of  the  buccal  surfaces,  giving  not  only  a  very 
natural  appearance,  but  acting  as  a  guard  to  the  cheek,  and  preventing 
its  being  caught  between  the  teeth. 

Fig.  698  illustrates  the  difference  of  shape  required  for  a  mouth 
where  front  absorption  permits  the  artificial  gum  to  overlap  the  alve- 

FiG.  698. 


olus,  and  one  where  fullness  of  the  natural  gum  requires  the  block  to 
set  directly  upon  it.  In  the  latter  case,  if  the  color  of  gum  is  judi- 
ciously chosen  and  the  blocks  well  adapted,  the  triangles  of  artificial 
gum  will  be  scarcely,  if  at  all,  distinguishable  from  the  natural ;  we 
regard  this  as  an  extremely  useful  form  of  block.     Sectional  view  of 


POKCELAIN  TEETH. 


927 


the  molar,  in  the  upper  cut,  shows  the  curve  necessary  to  bring  its 
grinding  surface  directly  under  the  ridge;  the  views  of  grinding  and 
cutting  surfaces,  together  with  front  views,  show  how  each  tooth  has  a 
distinctive  character ;  as,  for  instance,  in  the  bicuspids,  so  often  chosen 
without  regard  to  the  difference  in  form  between  the  first  and  second. 
Again,  the  curve  of  the  front  block  shows  two  of  several  variations 
required  in  the  curvature  of  the  arch ;  in  the  upper,  the  sharp  turn  at 
the  canine  gives  a  squareness  across  the  incisors ;  in  the  lower,  this 

Fig.  699. 


turn  is  at  the  central,  and  is  adapted  to  a  pointed  arch.  Variations 
in  curvature  of  the  arch  are  shown  also  in  Figs.  693,  706.  Notice  also 
the  marked  difference  in  the  character  of  the  bicuspids  and  molars  in 
upper  and  lower  cuts,  and  the  totally  different  expression  of  the  front 
teeth. 

Fig.  699  shows  how  the  same  intermaxillary  space  may  be  filled 
with  teeth  of  widely  different  size,  as  well  as  character.  In  the  first,  a 
very  long  tooth  and  short  gum ;  in  the  second,  a  very  long  gum  and 
short  tooth.     But  length  of  teeth  is  by  no  means  the  only  difference 

Fig.  700. 


here ;  relative  size  of  central  and  lateral,  direction  of  the  axis  of  lat- 
eral and  canine,  and  outline  of  cutting  edge  of  the  block,  are  three 
features  which  equally  mark  the  distinctness  of  these  two  styles  ;  these 
also  are  points  which  demand  that  both  long  and  short  teeth  shall 
differ  among  themselves  as  widely  as  these  samples  differ  from  each 
other.  The  lateral  view  of  these  teeth  shows  another  marked  difl^erence 
in  form. 

Fig.  700  gives  the  characteristic  equality  of  lower  incisors,  or  slightly 


928 


MECHANICS. 


greater  size  of  the  lateral ;  it  also  gives  some  of  the  diversities  in  length, 
width,  shape  of  cutting  edge,  and  form  at  arch  of  the  gum.  Although 
there  is  much  less  difference  in  the  shape  of  the  six  lower  front  teeth 
than  of  the  six  upper,  it  is  a  great  mistake  to  suppose  that  a  given 
lower  block  will  answer  for  any  lower  case,  if  only  long  enough.  Side 
views  show  also  a  difference  in  the  slant  of  the  teeth,  inward  or  out- 
ward, which  has  an  important  effect  in  modifying  the  expression  of 
the  lower  arch.  There  are  also  differences  in  curvature  of  the  lower 
arch  as  well  as  of  the  upper.  Fig.  693  shows  the  usual  upper  and 
lower  curves,  and  Figs.  698,  706  show  variations  of  upper  curvature 
requiring  some  modifications  of  the  lower,  dependent  on  the  character 
of  the  articulation.  In  Fig.  701  are  four  other  forms  of  lower  front 
blocks,  the  value  of  which  will  be  at  once  recognized.  The  two  right- 
hand  sets  differ  from  those  of  Fig.  700  mainly  in  the  length  and  width 
of  teeth.     The  left  lower  set  is  well  suited  to  patients  whose  natural 

Fig.  701. 


teeth,  for  many  years  before  their  loss,  were  marked  by  exposure  of 
the  neck ;  this  appearance  may  also  be  increased  (sometimes  it  may 
be  made)  by  judicious  use  of  the  corundum  wheel,  but  the  block  here 
given  is  invaluable  for  such  cases.  The  left  upper  block  is  an  admi- 
rable imitation  of  a  very  usual  arrangement  of  incisors,  resulting  from 
crowded  dentition ;  the  drawing  gives  a  very  imperfect  idea  of  the 
great  beauty  of  the  original  porcelain  block.  When  the  facial  expres- 
sion indicates  its  use,  it  will  have  great  effect  in  disarming  suspicion 
of  artificiality — a  very  desirable  quality  in  artificial  dentures. 

In  Fig.  702  we  have  very  convenient  modifications  to  suit  front 
spaces  of  two  or  four  teeth  ;  the  set  of  four  being  in  two  blocks.  The 
peculiarity  of  these  blocks  is  the  lateral  finish  of  the  gum ;  instead  of 
a  square  joint,  for  fitting  to  an  adjoining  block,  they  have  a  rounded 
edge,  of  gum  color,  that  can  be  adapted  to  the  curves  of  the  absorbed 
natural  gum.     There  should  also  be  blocks  of  two,  a  lateral  and  cen- 


PORCELAIN   TEETH. 


929 


tral,  with  gum  shaped  like  the  double  central,  as  such  spaces  are  of 
frequent  occurrence.  Besides  the  four  forms  of  teeth  here  given  there 
are  many  other  varieties,  in  size  and  shape,  of  this  very  useful  kind 
of  block. 

Figs.  703,  704,  and  705  represent  a  few  of  the  great  variety  of  forms 
of  upper  incisors  and  canines,  designed  to  meet  the  demands  of  an 
aesthetic  discrimination.  In  Fig.  703  we  have,  first,  a  long,  delicate 
lateral,  with  sloping  but  not  rounded  edge,  showing  a  decided  space 

Fig.  702. 


between  it  and  the  cuspid  and  central ;  then  we  find  it  wider,  Avith 
corners  and  edge  rounded  and  filling  the  space.  Lastly,  for  want  of 
space,  the  laterals,  although  long  and  narrow,  overlap  the  centrals ; 
this  style  is  generally  accompanied  with  a  pointed  arch.  The  fourth 
block,  although  with  an  overlapping  incisor,  has  an  entirely  different 
character ;  it  is  often  found  in  a  rather  flattened  arch,  and  does  not 
indicate  a  crowded  denture.  In  these  blocks  the  inclination  and 
shape  of  the  canine,  as  well  as  the  shape  of  the  incisor,  help  to  give  to 

Fig.  703. 


each  block  a  distinctness  of  character  which  will  not  permit  the  use  of 
one  in  a  case  demanding  either  of  the  others. 

The  celare  artevi  effect  of  overlapping  or  twisted  laterals,  like  that  of 
irregular  lower  incisors,  is  such  as  to  tempt  one  to  use  them  whenever 
admissible.  In  Fig.  704  we  have  some  additional  varieties  of  this  kind 
of  block.  In  all  these  six  cases  we  find  differences  in  the  size  and 
character  of  the  lateral,  in  the  extent  of  its  lapping,  and  in  the  degree 
of  twist  given  to  it.     A  careful  study  of  natural  teeth  will  teach  the 

59 


930 


MECHANICS. 


dentist  what  character  of  face  is  best  suited  to  each  of  these  different 
forms,  and  thus  he  will  much  increase  the  extent  to  which  he  may 
properly  use  this  kind  of  irregularity. 

In  Fig.  705  the  blocks  vary  little  in  size,  yet  they  each  have  a  dis- 
tinctive character.  In  the  first,  we  have  lateral  rounded  on  both 
corners,  and  its  axis  vertical ;  canine,  with  pointed  cusp  and  edges  quite 
rounded.  In  the  second,  we  have  lateral  inclined,  with  median  corner 
pointed,  lateral  corner  quite  round  ;  canine  with  blunt  cusp,  also  axis 
inclined.  In  the  third,  surface  of  the  canine  is  decidedly  furrowed, 
which,  with  the  indented  edge,  gives  it  a  marked  character ;  the  lateral 
and^  central,  unlike  the  previous  blocks,  have  square-cut  edges,  with 
corners  but  slightly  rounded.  In  the  fourth,  the  lateral  is  more  nearly 
equal  to  the  central,  and  none  of  the  teeth  may  have  any  marked 
peculiarities;  this  style  of  block,  in  its  different  sizes,  suits  well  in 
many  cases,  and  is  perhaps  one  of  the  best  for  general    use  by  those 

Fig.  704. 


practitioners  who  pay  no  regard,  in  their  selection  of  teeth,  to  the  indi- 
cations given  by  the  physical  characteristics  of  the  face  and  head. 
The  fifth  block  is  one  of  that  class  often  met  with  in  old  age,  where, 
by  the  action  of  the  lower  teeth  or  other  causes,  the  arch  has  spread, 
widening  the  interdental  spaces.  The  interdental  gum  is  also  much 
shorter  than  in  youth,  as  is  finely  shown  in  the  original  from  which 
this  cut  is  taken. 

In  the  selection  of  porcelain  blocks,  not  only  must  the  color,  size, 
and  form  of  the  teeth  be  carefully  considered,  but  reference  must  also 
be  had  to  the  curvature  of  the  arch.  For  although  moderate  varia- 
tions in  curvature  can  be  fitted  by  the  same  set  of  blocks,  the  true 
expression  of  a  porcelain  denture  is  often  lost  by  the  attempt  to  adapt 
it  to  a  curve  for  which  it  was  not  designed.  In  Figs.  693,  698  and 
706  we  have  various  curves  of  the  alveolar  arch,  with  corresponding 
variations  in  shape  of  the  blocks.     Sometimes  the  canines  are  made 


PORCELAIN   TEETH. 


931 


separate,  with  a  view  to  increase  the  range  of  application  of  a  given 
set;  but  a  joint  on  either  side  is  very  apt  to  injure  the  effect  of  this 
important  tooth.  In  the  lower  jaw  it  is  of  less  consequence  because 
the  gum  is  less  often  exposed,  and  it  is  frequently  desirable  to  make 
the  four  incisors  in  one  block.  But  in  the  upper  jaw,  it  is  much 
better  to  have  a  median  joint,  and  another  behind  the  canines. 

In  Fig.  706  the  reader  will  notice  that  the  centrals  of  the  first  set 
overlap  the  laterals,  an  arrangement  of  frequent  occurrence  in  promi- 
nent and  sharply  curved  arches.  It  will  be  observed  that  in  Fig.  696 
the  blocks  are  so  shaped  that  the  right  or  left  central  overlaps  its  fel- 
low. Thus  we  have  three  varieties  of  overlapping  upper  teeth  ;  laterals 
over  centrals,  centrals  over  laterals,  central  over  central ;  each  of  which 
may  be  used  with  great  effect,  if  applied  with  discrimination.  In  the 
third  set  of  Fig,  706,  and  in  a  few  of  the  preceding  cuts,  the  gum  over 

Fig.  705. 


the  cuspids  is  very  strongly  marked.  This  is  a  very  characteristic 
feature  of  some  mouths,  and  when  correctly  used  gives  a  fine  effect ; 
but  it  would  sadly  belie  the  expression  in  a  timid  and  gentle  lady's 
face.  Yet  such  incongruity  is  only  one  of  hundreds  constantly  occur- 
ring, where  every  sense  of  sesthetic  beauty  and  harmony  is  violated ; 
teeth  of  a  Russian  in  the  mouth  of  a  Frenchman ;  those  of  a  New 
Englander  given  to  a  South  Carolinian,  or  those  of  a  Canadian  to  a 
Cuban — the  lips  of  age  disclosing  the  teeth  of  youth,  and  no  distinc- 
tion made  between  a  male  and  a  female  denture.  These  sesthetic 
blunders  are  not  confined  to  the  inexperienced  tyro,  but  are  perpe- 
trated by  many  who  presume  to  call  themselves  skillful  mechanicians. 
When  we  consider  the  extensive  assortment  of  porcelain  teeth  which 
ceramic  art  has  placed  at  the  disposal  of  the  practitioner,  such  mal- 
practice is  without  excuse. 


932 


MECHANICS. 


These  are  only  a  few  out  of  the  great  number  of  varieties,  in  size, 
form  and  arrangement,  of  porcelain  teeth  ;  they  give  to  the  dentist  a 
much  wider  range  of  selection  than  some  have  the  ability  or  inclina- 
tion to  avail  themselves  of  When  to  variety  of  shape  we  add  shades 
of  color,  the  number  of  sets  that  admit  of  being  made,  distinguishable 

Fig.  706. 


■-<a^       ^        ^ 


W  '>-'  ^ 


at  a  glance  from  each  other,  seems  almost  infinite.  A  visit  to  a  first- 
class  porcelain  tooth  manufacturer's  rooms  will  convince  any  one  that 
incongruity  or  want  of  expression  in  a  set  of  teeth  is  the  fault  of  him 
who  selects  and  applies,  rather  than  of  him  who  designs  and  makes 
dental  porcelain. 


PORCELAIN   TEETH.  933 

It  -will  be  perceived  that  the  foregoing  illustrations  *  of  the  aesthetic 
principles  of  the  dento-ceraraic  art  are  taken  from  one  class  of  teeth, 
those  for  vulcanite  or  metallo-plastic  work.  We  have  done  so  because 
the  art  has  here  had  its  fullest  recent  development,  in  consequence  of 
the  great  demand  for  this  form  of  block.  '  But  dental  aesthetics  is  quite 
independent  of  the  material  of  the  plate,  so  long  as  that  which  is 
visible  in  the  mouth  is  porcelain ;  and  dentures  which  show  any  sub- 
stitute for  the  gum  other  than  this,  however  useful  they  may  be, 
cannot  rank  as  specimens  of  highest  art,  until  some  material  for  the 
plate  shall  be  discovered  possessing  higher  claims  to  beauty  than  any 
yet  known. 

The  foregoing  rules  will  apply  to  the  form  and  size  of  plain  teeth 
when  these  are  set  directly  upon  the  natural  gum;  but,  except  in 
case  of  true  pivot  or  plate-pivot  teeth,  it  is  impossible  to  reproduce  the 
precise  natural  arching  of  the  gum  above  the  tooth  without  some  gum- 
colored  porcelain.  We  must  often  be  content,  in  such  cases,  with  the 
nearest  possible  approach  to  nature.  But  when  the  plate  is  seen  on 
the  outside  of  the  arch,  the  artist's  reputation  is  dependent  upon  the 
concealment  of  the  greater  part  of  his  work ;  even  here,  however,  the 
cutting  edge  and  two-thirds  of  the  tooth  permit  the  display  of  great 
varieties  of  expression.  Of  plain  teeth  without  gum  there  are  four 
kinds.  1.  Pivot  teeth  ;  shaped  somewhat  like  the  crowns  of  the  upper 
incisors  and  canines,  with  a  hole  in  the  base,  for  insertion  of  a  wooden 
pivot.  2.  Plate  teeth ;  the  oldest  known  form  of  porcelain  teeth  hav- 
ing pins  for  attachment  of  a  back,  by  which  to  secure  it  to  the  plate. 
3.  Continuous-gum  teeth ;  resembling  natural  teeth  in  having  a  root, 
which  is  more  or  less  serrated,  for  better  retention  in  the  investing 
porcelain  base ;  they  are  sometimes  made  without  platina  pins ;  but 
they  are  better  with  pins,  so  that  they  may  be  securely  fastened  to  the 
platina  plate.  4.  Plain  vulcanite  (Fig.  711);  having  a  small  neck, 
by  w^hich  they  are  held  in  the  vulcanite  or  other  material  in  which 
they  are  set.  These  teeth  may  be  set  directly  on  the  gum  by  grinding 
oif  the  neck ;  they  may  also  be  used  adjacent  to  natural  teeth  with 
exposed  neck,  by  slight  alteration  of  this  neck,  so  as  to  give  to  the 
artificial  tooth  the  same  appearance  as  the  natural  one. 

*  We  are  indebted  to  the  kindness  of  the  late  Dr.  Samuel  S.  White,  and  more 
recently  of  the  S.  S.  White  Dental  Mauufacluring  Company,  of  Philadelphia, 
for  the  admirable  illustrations  by  the  aid  of  which  we  have  been  enabled  to  ex- 
press our  views  upon  the  important  subject  of  dental  ^Esthetics.  No  illustra- 
tions, however,  can  convey  a  true  idea  of  the  high  artistic  excellence  of  those 
forms  the  production  of  which  has  placed  Dr.  White  among  the  greatest  benefac- 
tors of  Dental  Art.  We  take  this  occasion  to  acknowledge,  also,  the  liberality 
and  courtesy  with  which  our  inquiries  for  information  on  the  manufacture  of 
dental  porcelain  were  responded  to  by  this  gentleman. 


934 


MECHAXICS. 


There  are  also  other  forms  of  gum  teeth  besides  those  above  repre- 
sented. Formerly,  single  gum  teeth  were  extensively  used  on  gold 
plate,  and  may  still  be  occasionally  required  when  the  supremacy  of 
that  old-fashioned  material  becomes  once  more  recognized  in  the  labo- 
ratory. The  great  facility  of  adapting  blocks  or  sections  in  vulcanite 
work,  or  in  vulcanite  attachment  to  swaged  plates,  has  led  to  the  almost 
entire  exclusion  of  this  form  of  tooth,  except  for  repairing.  A  serious 
objection  to  single  gum  teeth  is  the  number  of  joints ;  these  greatly 
mar  the  artistic  effect  which  it  is  the  design  of  the  artificial  gum  to 
produce,  especially  when  not  kept  perfectly  clean,  or  when  the  material 
of  plastic  plates  is  allowed  to  enter  the  joints.  Figs.  692  and  707  are 
designed  to  show  the  importance  of  correct  and  accurate  grinding  in 

Fig.  707. 


order  to  display  the  true  character  of  a  set  of  teeth.  When  properly 
done,  the  joint  does  not  interrupt  the  continuous  surface  of  the  gum 
more  than  the  lines  in  the  two  lower  sets  of  Fig.  707  ;  nor  should  it 
in  any  case  be  more  visible  than  the  heavier  lines  of  the  first  set. 
Neither  should  the  set  be  so  inaptly  chosen  as  to  require  such  grind- 
ing of  joints  and  base  as  to  injure  its  original  expression.  Figs.  692 
and  707  should  also  be  carefully  studied  by  the  student,  on  account 
of  the  varieties  of  form  and  relation  of  teeth  presented ;  each  of  the 
four  upper  sets  here  displayed  having  a  very  distinctly  marked 
character. 

Porcelain  blocks  which  are  to  be  attached  to  a  gold  plate  by  solder- 
ing do  not  differ  in  external  appearance  from  the  forms  already  illus- 
trated ;  but  the  shape  of  inner  surface  and  the  form  of  the  pins  are 


PORCELAIX   TEETH.  935 

different.  Fig.  708  represents  such  a  set  of  upper  blocks  in  three 
sections.  If  made  in  four  sections,  the  set  should  be  divided  between 
the  centrals  and  between  the  bicuspids ;  it  may  also  be  in  five  sections, 
the  four  joints  being  in  front  of  the  cuspids  and  behind  the  bicuspids; 
or  it  may  be  divided  into  six  sections,  as  in  Fig.  692.  The  line  above 
the  pins  in  Fig.  708  marks  the  division  between  the  inner  slope  of 
gum  next  the  teeth  and  the  plain  surface  holding  the  pins ;  this  sur- 
face should  be  as  smooth  as  possible,  for  the  perfect  adaptation  of  the 
gold  backing.  Blocks  may  also  be  made  in  sets  of  three  or  five  sec- 
lions,  with  the  inner  surface  finished  in  gum  enamel  to  the  plate ;  in 
this  case  the  block  is  held  to  the  plate  by  pins  passing  into  holes  made 
in  its  base,  one  opposite  each  tooth.  The  best  material  for  retaining 
the  pins  is  undoubtedly  vulcanite,  as  described  in  the  previous  chapter ; 
the  holes  should  be  rough,  for  its  better  adhesion. 

The  dental  depots  cannot  keep  on  hand  an  assortment  of  such  blocks, 
since  the  demand  is  too  limited  to  justify  the  expense  of  the  brass 
moulds.  But  in  all  our  principal  cities  there  will  be  found  one  or 
more  dental-block  carvers,  whose  experience  and  constant  practice 
enable  them  to  make  any  style  of  blocks  that  may  be  desired  for 
special  cases.  We  have  elsewhere  given  our  reasons  for  thinking  this 
a  better  plan  than  for  the  dentist  himself  to  attempt  occasional  ceramic 
experiments.  Let  him  prepare  an  accurate  articulatiug  model,  and 
adapt  a  tin-foil  plate  (to  avoid  the  risk  of  sending  the  gold  one;  ;  then 
select  one  or  more  teeth,  to  guide  the  carver  in  the  required  color  and 
character  of  the  set.  If  any  peculiar  form  or  deviation  from  the 
normal  arrangement  is  desired,  this  should  be  represented  in  wax ; 
then  pack  carefully,  and  send  to  the  block  carver.  This  plan  is  recom- 
mended to  those  who  may  desire,  for  some  special  case,  a  form  of  blocks 
not  to  be  had  at  the  depots.  Xecessarily  such  blocks  are  much  more 
expensive  than  those  made  by  the  quantity  in  brass  moulds  ;  but  if  the 
dentist  values  his  time,  the  blocks  would  cost  still  more  if  made  by 
himself. 

The  true  question  is,  however,  not  one  of  cost ;  if  the  depot  can 
furnish  the  form  of  blocks  which  the  case  requires,  it  is  best  to  get 
them  there,  otherwise,  they  must  be  had  elsewhere  and  at  any  cost. 
Dental  tradesmen,  who  sell  their  "wares  at  a  moderate  advance  on  the 
cost  of  production,  may  not  deem  it  prudent  to  deal  in  such  high-priced 
materials;  but  the  professional  dentist,  who  charges  for  "services  ren- 
dered," will  never  find  it  necessary  to  hesitate  incurring  any  expense 
requisite  for  the  perfection  of  his  work.  The  actual  cost  of  material 
in  single  dentures  has  often  exceeded  thirty  dollars ;  yet  the  mechani- 
cian who  exercises  a  skill  commensurate  with  this  cost  never  has  found, 
and  never  will  find,  diiEculty  in  adding  a  just  compensation  for  his  time 


936 


MECHANICS. 


and  skill.  As  a  rule,  patients  will  pay  best  for  art  when  exercised  on 
expensive  material,  except  where,  as  in  painting,  the  effect  produced 
is  wholly  irrespective  of  the  cost  of  the  means  employed.  The  true 
basis  of  professional  fees  lies  in  that  which  makes  one  man's  work 
superior  to  another's;  namely,  artistic  skill  exercised  upon  materials, 
the  quality  of  which  shall  not  detract  from  its  just  appreciation. 

As  we  have  briefly  described  the  processes  of  manufacture  of  porce- 
lain dentures  on  a  large  scale — a  work  which,  of  course,  no  practicing 
dentist  proposes  to  engage  in — it  is  proper  that  we  should  also  give 
a  brief  description  of  the  processes  by  which  blocks  are  carved  for 
special  cases,  although  we  regard  this  as  equally  out  of  the  line  of  the 
modern  dentist's  duties.  We  occasionally  find  a  genius,  whose  gift 
shows  that  ceramic  art,  not  dentistry,  is  his  true  profession  ;  but  men 
engaged  in  ordinary  dental  practice  must,  in  justice  to  their  patients, 
make  use  of  the  experience  of  professional  block  carvers,  or  they  must 
use  those  forms  offered  by  the  ceramic  manufacturer,  which  are  the 
results  of  the  highest  artistic  skill  which  money  can  command. 


Fig.  709. 


SPECIAL   BLOCK   CAEVING. 

To  make  a  porcelain  dental  arch  in  three  sections  for  a  full  upper 
ease  antagonizing  with  natural  teeth  below,  make  a  plaster  articu- 
lator, as  described  in  the  tenth  chapter,  but  having  greater  thickness,  to 
permit  guiding  holes  or  grooves,  as  in  Fig.  709.  Open  the  articulator, 
increasing  the  space  one-fifth  (unless  this  one-fifth  enlargement  is  to 
be  made  by  addition  of  point  enamel) ;  place  on  the  plate  a  wax  rim, 
and  trim  it  to  antagonize  with  the  lower  teeth,  giving  the  precise  ex- 
ternal fullness  required  in  the  blocks.    Mark  on  wax  and  front  edge  of 

articulator  the  medial  line  and  the  lines 
of  proposed  division  of  blocks  ;  that  is,  be- 
tween bicuspids  for  a  four-block  piece,  and 
behind  cuspids  for  a  piece  of  three  blocks  ; 
in  either  case  the  work  is  carved  in  three 
pieces.  It  is  also  well  to  mark,  in  fainter 
lines,  the  width  of  each  tooth  as  deter- 
mined by  the  size  of  the  lower  teeth;  this 
will  be  some  guide  in  the  subsequent  en- 
largement, required  on  account  of  shrink- 
age of  the  porcelain  paste.  Next  make  a 
plaster  rim  about  half  an  inch  thick  (Fig. 
584,  on  page  768,  shows  the  height  and 
thickness),  covering  the  exterior  surface 
of  model  and  wax  ;  making  first  the  front 
section,    extending    a    half   tooth   space 


PORCELAIN   TEETH.  937 

behind  the  lines  marked  for  the  block  joints ;  then  remove  this,  and 
make  the  two  side  sections,  extending  each  a  half  tooth  space  in  front 
of  these  lines.  The  use  of  a  leaden  band  and  some  paper  pulp  will 
expedite  the  making  of  these  plaster  sections ;  they  should  be  trimmed 
to  the  exact  length  required  for  the  crude  blocks.  Of  course,  neither 
in  plaster  nor  porcelain  can  the  front  and  side  sections  be  applied  to 
the  model  or  plate  at  the  same  time,  in  consequence  of  the  one-fifth 
allowance  for  thickness. 

On  removing  the  wax,  each  plaster  section  is  a  matrix  to  determine 
the  external  fullness  of  the  corresponding  block,  on  which  is  to  be 
carved  the  shape  of  teeth  and  gum.  The  plate  gives  exact  form  to 
the  base  of  the  block ;  but  when  finished,  it  will  require  grinding,  be- 
cause of  the  derangement  of  fit  caused  by  shrinkage.  The  thickness 
and  interior  form  of  the  sections  is  determined  by  the  eye,  and  will 
vary  with  the  style  of  finish  or  mode  of  attachment,  being  careful,  in 
this  direction  also,  to  make  the  one-fifth  allowance  for  shrinkage.  The 
front  block  is  first  made  and  removed,  then  each  side  block  separately  ; 
in  a  double  set,  both  front  blocks  are  made,  then  both  right  sections 
together  and  left  sections  together,  so  as  to  obtain  their  proper  antago- 
nism ;  also,  in  double  sets,  the  separation  of  the  articulation  must  be 
sufficient  to  allow  the  one-fifth  enlargement  in  each  set. 

The  porcelain  body  is  prepared  as  already  explained  ;  it  can  be 
compounded  by  the  dentist,  or  purchased  from  the  manufacturer.  In 
mixing  the  small  quantities  required  for  single  cases,  two  points  demand 
special  carcT— purity  of  the  water  and  absolute  exclusion  of  air  from 
the  mass.  It  must  also  be  remembered  that  irregular  contraction,  or 
warping  of  blocks  in  firing,  is  often  caused  by  unequal  compression  in 
packing  the  body  into  the  moulds,  and  by  unequal  absorption  of  its 
moisture,  by  the  porous  plaster  rim  or  other  means  used  to  dry  it. 
Again,  it  should  be  remembered,  in  removing  the  rim,  in  carving  and 
in  all  other  operations  on  the  crude  paste,  that  the  excess  of  feldspar 
gives  it  a  tenderness  very  different  from  the  tough  plasticity  of  a 
kaolin  mass.  The  putty-like  body  is  to  be  carefully  worked  into  the 
well-oiled  mould,  compressed  with  the  fingers,  trimmed  into  outline 
shape,  and  then  removed,  first  marking  upon  it  the  lines  of  the  articu- 
lator, to  guide  in  the  carving.  The  block  may  be  partly  or  entirely 
carved  while  on  the  articulator  ;  but  the  delicate  movements  of  the 
very  delicately-shaped  carving  tools  are,  in  the  opinion  of  some,  best 
exercised  upon  the  free  block. 

For  Carving,  no  directions  can  be  given  beyond  what  has  heretofore 
been  said  on  the  necessity  of  a  close  observance  and  exact  copying  of 
nature.  The  artist  requires  no  written  directions,  and  paper  instruc- 
tions never  yet  made  an  artist  out  of  a  bungler  ;  in  fact,  the  heaven- 


938  MECHANICS. 

born  genius  of  art  cannot  be  created  by  teaching,  however  it  may  be 
trained  and  directed.  Many  have  wasted  years  in  porcelain  block 
carving,  only  to  produce  results  surpassed  by  the  least  artistic  forms 
offered  in  the  depots;  while,  on-  the  other  hand,  some  dental  Palissy 
will  work  out  a  marvel  of  beauty  that  no  purchased  blocks  can  equal. 
But  before  one  imagines  himself  a  Bernard  Palissy,  let  him  read  the 
history  of  that  wonderful  struggle  of  genius  ;  then  ask,  how  far  the 
routine  duties  of  a  dental  of&ce  will  permit  an  exclusiveness  of  devo- 
tion, which  ceramic  art  rigorously  exacts  as  a  condition  of  success. 

"When   carved,  the  blocks    are  thoroughly  dried,  then  placed  on 
coarse  silex  upon  a  fire-clay  slab,  and  set  into  the  muffle  of  the  furnace, 
(Fig.  710).     Here  they  are  biscuited  (or  cruced),  that  is,  raised  to  a 
red  heat  suffioient  to  give  some  hardness,  but  not  to  vitrify  or  even  to 
cause  incipient  fusion.     They  are  then  slowly  cooled,  and  holes  drilled 
for  the  pins,  or  else  holes  drilled  into  the  base  of  the  blocks,  as  may 
be  preferred  ;  the  pins  are  fastened  in  place  by  a  little  "  body-slip," 
carefully  worked  in  with  the  knife  point.     Slight  defects  of  carving 
may  now  be  corrected  ;  the  enamels  are  then  applied  with  a  camel's 
hair  brush.     They  must  be  reduced  to  the  consistence  of  cream,  and 
require   much   skill  and  judgment  in  their  application,  so  that  the 
point  enamel  shall  blend    properly  with   the   body  enamel ;  also   the 
gum  enamel  must  preserve  its  distinctness  of  outline,  and,  by  its  vary- 
ing  thickness,  give  those   alternations  of   shade   observable  in    the 
natural  gum.     It  should  here  be  remarked,  that  some  carvers  make 
no  allowance  in  the  body  for  shrinkage  in  length  of  the  tooth,  but 
compensate  by  the  addition  of  point  enamel.     The  crowns  of  bicuspids 
and  molars  are  usually  enameled  ;  also  part  of  the  inner  surface  of 
the  blocks,  and  in  some  blocks  the  gum  enamel  extends  to  the  base. 
When  platina  pins  are  inserted,  the  part  of  the  block  to  be  covered  by 
the  backing  is  not  enameled.     It  is  scarcely  necessary  to  remark  that 
a  large  assortment  of  body,  point,  and  gum  enamels  is  required  ;  also 
that  these  must,  with  great  care,  be  kept  separate,  with  their  respective 
test  pieces  attached ;  for,  except  by  the  pinkish  color  of  gum  enamel, 
they  cannot  be  distinguished  when  in  form  of  powder,  paste  or  cream. 
The  blocks  are  now  well  dried,  and  are  ready  for  the  furnace,  Fig. 
710.     (For  other  forms  of  furnaces,  see  article  on  "  Continuous  Arti- 
ficial   Gum.")     Success   thus   far   is  dependent    upon  :  1.  Thorough 
mixing  of  the  body  and  its  careful  packing ;  2.  Skillful  carving,  so  as 
not  only  to  give  the  required  expression,  but  also  to  know  what  allow- 
ances to  make  at  each  point  for  shrinkage  and  for  the  subsequent 
application  of  the  enamels  ;  3.  Selection  of  enamels  and  their  skillful 
blending  and  shaping;  4.  The  giving  of  such  form,  in  adjustment  of 
the  relative  length  and  thickness  of  each  block  and  apportionment  of 


PORCELAIN  TEETH. 


939 


material,  as  shall  prevent  warp-  Fig.  710. 

ing  in  the  furnace.  These  points, 
however,  may  have  been  perfectly 
attended  to ;  yet  all  will  have 
been  done  in  vain,  unless  the  op- 
erator has  a  thorough  practical 
knowledge  of  the  management  of 
the  furnace.  It  is  this  which 
makes  the  ceramic  experiments 
of  the  practicing  dentist  so  often 
a  failure  ;  for  fail  he  certainly 
will  unless  he  knows  the  exact 
heat  at  which  the  differing  fusi- 
bilities of  his  body  and  various 
enamels  will,  by  their  combined 
effect,  develop  the  properties 
aimed  at  in  their  composition. 
Some  are  governed  in  this  by 
test  pieces ;  the  experienced  work- 
man, guided  by  constant  practice 
in  a  way  that  he  cannot  explain, 

prefers  the  indications  offered  by  looking  at  the  piece  itself.  If  not 
sufficiently  baked,  the  body  will  be  porous  ;  also  neither  this  nor  the 
enamels  will  have  their  true  life-like  character.  If  overdone,  there  is 
an  offensive,  glassy,  and  transparent  condition,  equally  fatal  to  the 
natural  appearance ;  also,  there  is  too  much  shrinkage  and  greater 
danger  of  warping.  Both  errors  impair  the  full  strength  of  the 
porcelain,  in  which  the  ingredients  are  so  combined  as  to  develop 
greatest  strength  at  a  certain  temperature. 

Furnace  temperature  is  measured  by  instruments  called  Pyrometers. 
The  limit  of  mercurial  registration  of  temperature  is  600°  Fahrenheit. 
Daniell's  pyrometer  registers  by  the  expansion  of  a  platina  rod  in  a 
plumbago  case,  and  is  the  most  accurate.  Wedgewood's  pyrometer 
registers  by  the  rate  of  permanent  contraction  of  kaolin  under  intense 
heat.  A  clay  wedge,  fitting  the  upper  part  of  a  tapering  groove,  will, 
after  exposure  to  furnace  heat,  slip  further  into  the  groove ;  supposing 
the  rate  of  contraction  uniform,  this  distance  will  be  a  measure  of  the 
heat,  after  establishing  its  exact  relation  to  the  600°  point  of  Fahren- 
heit. But  the  contraction  of  any  two  pieces  is  not  the  same,  unless 
their  composition  is  identical ;  also,  the  relation  to  the  mercurial  scale 
is  not  easy  to  determine.  Wedgewood's  zero  was  1076^  Fahrenheit, 
and  he  estimated  one  degree  of  his  pyrometer  equal  to  130°;  on  which 
basis  of  calculation  the  highest  heat  of  the  porcelain  furnace  (130°  to 


940  MECHANICS. 

160°  Wedgewood)  would  range  from  19,000°  to  22,000°  Fahrenheit. 
Others  estimate  his  degree  at  62.5°  Fahrenheit,  reducing  the  registra- 
tion from  9500°  to  11,000°  Fahrenheit,  Taking  the  fusion  point  of  gold 
at  2000°,  and  of  pure  iron  at  3000°,  we  thus  have  some  idea  of  the 
infusibility  of  platinum  and  the  extreme  heat  of  ceramic  furnaces. 
But  it  is  evident  that  the  correct  regulation  of  this  heat  must  be  the 
result  of  experience  rather  than  of  written  direction ;  also,  that  the 
furnace  practice  of  diiferent  persons  cannot  be  accurately  compared. 

The  muffle  protects  against  the  gases  of  the  fire.  Charcoal,  coke,  or 
anthracite  are  used  as  fuels,  according  to  the  location  of  the  operator ; 
the  last  is  preferable  when  it  can  be  procured,  because  it  gives  the 
steadiest  heat ;  charcoal  requires  practice  to  maintain  a  uniform  heat ; 
coke  is  used  in  all  the  bituminous  coal  regions.  With  either  of  these,  after 
sufficient  experience,  a  furnace  may  be  kept  regularly  at  the  required 
heat  for  a  length  of  time  sufficient  to  fire  the  porcelain  blocks.  They 
must  be  thoroughly  dried  on  the  furnace-shelf  before  going  into  the 
muffle ;  the  mouth  of  the  muffle  should  be  well  luted,  and  the  stopper 

Fig.  711. 


withdrawn  only  to  examine  the  Avqrk.  The  more  slowly  blocks  are 
cooled,  the  more  perfectly  are  they  annealed,  and  hence  less  liable  to 
crack  from  sudden  changes  of  temperature,  as  in  soldering. 

Not  to  interrupt  the  order  of  operations,  we  have  deferred  the  de- 
scription of  a  very  ingenious  method  of  carving  devised  by  Dr.  Wm. 
Calvert.  Instead  of  the  wax  rim  before  mentioned.  Dr.  Calvert  pro- 
vided an  assortment  of  teeth  having  all  the  varieties  of  form  and  size 
required  in  practice,  but  one-fifth  larger  than  the  given  case.  These 
are  arranged  in  a  wax  gum,  and  the  plaster  mould  then  taken.  Thus, 
in  Fig.  711,  teeth  of  the  first  size,  set  in  wax,  will  give,  when  dimin- 
ished by  the  furnace,  teeth  of  the  second  size ;  so  in  Fig.  640,  each  of 
the  two  lower  sizes  in  wax  will  give,  in  the  finished  block,  the  size 
above  it.  Dr.  Calvert's  method  has  three  recommendations  :  1.  Like 
continuous-gum  work,  it  limits  the  necessity  of  aesthetic  skill  (which 
so  few  possess  in  high  degree)  to  the  shaping  of  the  gum,  the  judicious 
selection  of  teeth,  and  their  proper  arrangement ;  leaving  the  details 
of  form  to  the  genius  of  the  manufacturer's  artist,     2.  It  permits  the 


PORCELAIN    TEETH.  941 

application  of  enamels,  or  rather  the  addition  of  body  to  enamels,  with- 
out the  necessity  of  crucing,  which  some  regard  as  injurious  to  the 
tooth.  3.  By  selecting  a  variety  of  styles  of  model  teeth,  and  by 
varying  the  relative  adjustment  of  them  in  the  wax,  that  tendency  to 
uniformity  of  style  is  obviated,  which  characterizes  almost  every  block 
carver's  work. 

Dr.  Calvert's  process  differs  mainly  from  the  foregoing  in  the  follow- 
ing details:  For  a  four-block  piece  the  teeth  are  set  in  wax  shaped  in 
exact  imitation  of  the  natural  gum,  omitting  the  second  bicuspid,  in 
place  of  which  a  half  tooth  space  is  left  between  first  bicuspid  and 
molar,  the  wax  gum  being  carried  around  continuously.  The  plaster 
mould  of  the  eight  front  teeth  is  then  taken,  a  thin  septum  of  foil  being 
placed  opposite  the  mesial  line,  so  that  it  may  be  easily  broken  there 
in  the  act  of  removal,  the  plaster  coming  slightly  over  the  inside,  so 
as  to  give  with  certainty  the  shape  of  the  cutting  edges.  Upon  remov- 
ing the  front  mould,  and  before  making  the  lateral  moulds,  where  as 
yet  the  wax  holds  only  two  molars,  it  is  necessary  to  detach  the  bicus- 
pid of  the  front  block  and  put  it  adjacent  to  the  molar ;  this  gives  the 
arch  its  full  complement  of  bicuspids.  This  must  be  done  very  neatly, 
so  as  not  to  disturb  the  continuity  of  the  wax  gum ;  otherwise,  the 
effect  of  the  porcelain  blocks  at  their  joints  will  be  injured.  Dr.  Cal- 
vert prefers  using  cuspids  for  insertion  in  the  wax  instead  of  bicuspids, 
since  their  external  expression  is  similar  and  their  form  more  conve- 
nient, especially  in  the  change  just  described.  By  similarity  of  form 
we  do  not.  mean  that,  in  any  mouth,  the  canines  and  bicuspids  are 
alike  externally ;  but,  out  of  a  collection  of  canines,  after  choosing 
the  cuspids  themselves,  others  may  be  selected,  harmonizing  with  them 
as  first  and  as  second  bicuspids.  Besides  overlapping  the  blocks  at  the 
bicuspids,  to  compensate  shrinkage,  a  slight  extension  of  each  block 
beyond  the  last  tooth  should  be  made,  to  allow  for  accurate  grinding. 
If  holes  are  made  in  the  base,  instead  of  platina  pins  in  the  back,  it 
will  be  best  to  make  a  continuous  front  block  of  six  teeth,  in  which 
case  the  half  tooth  space  above  named  comes  behind  the  cuspid. 

Since  the  carved  wax  and  the  contained  teeth  make  carving  of  the 
porcelain  paste  unnecessary,  the  plaster  moulds  are  varnished,  oiled, 
and  treated  as  are  the  brass  moulds  in  wholesale  manufacture.  The 
stiff  paste  of  point  enamel  is  placed,  with  a  delicate  spatula,  into  each 
tooth  matrix,  thickest  at  the  point,  and  disappearing  at  the  neck.  The 
tooth  enamel  paste  is  then  applied,  with  thickness  reversed ;  gum 
enamel  might  also  be  added  in  the  same  way,  but  it  is  usually  applied 
afterward  with  the  brush,  as  this  permits  delicacy  and  uniformity  of 
coating  or  easier  modification  of  its  thickness.  A  layer  of  soft  body 
paste  is  now  laid  over  the  enamels,  the  mould  is  placed  on  the  articu- 


942  MECHANICS. 

lator,  and  the  thickness  of  tlie  block  is  built  out  and  shaped  in  the 
usual  way,  compressing  it  firmly,  and  removing  surplus  moisture  with 
bibulous  paper  or  the  blowpipe  flame.  The  block  is  next  carefully 
removed,  and,  while  resting  in  its  matrix,  the  platina  pins  are  inserted 
or  holes  drilled  in  the  base,  or  dovetails  cut,  as  may  be  preferred,  and 
the  whole  inner  surface  examined  and  trimmed.  If  the  inside  of  the 
block  is  to  be  finished  in  gum,  the  enamel  should  now  be  applied  ;  then 
remove  the  block  from  the  matrix  and  apply  the  outside  gum  enamel, 
and  trim  between  the  teeth,  where  the  thin  edges  of  the  plaster  matrix 
are  apt  to  be  defective ;  the  block  is  then  ready  to  be  dried  and  placed 
in  the  furnace,  where  it  is  fired  at  a  single  heat  without  previous 
biscuiting.    The  side  blocks  are  made  in  precisely  the  same  manner. 

PORCELAIN  PLATES. 

In  addition  to  what  has  already  been  said  upon  this  subject,  it  is 
only  necessary  here  to  consider  some  of  the  preceding  properties  and 
manipulations  of  the  porcelain  material,  in  its  use  as  a  plate.  Neither 
in  itself,  nor  by  known  combination  with  any  substances,  can  a  thin 
porcelain  plate  be  otherwise  than  frail.  The  fusible  porcelain  of  the 
"  continuous-gura  work  "  is  supported  by  the  platina  plate  and  the 
continuously  soldered  platina  backings  Such  porcelain,  Avithout 
metallic  support,  would  be  very  frail.  In  endeavoring  to  give 
strength,  by  decreasing  the  flux  and  increasing  the  refractory  in- 
gredients, we  are  at  once  met  by  the  difiiculty  of  shrinkage.  Thus 
we  encounter  two  horns  of  a  dilemma — a  very  fusible  porcelain 
with  less  contraction,  but  great  tenderness ;  a  more  refractory  porce- 
lain with  greater  strength,  but  the  usual  one-fifth  contraction,  which 
necessarily  destroys  the  fit  of  the  plate,  if  made  over  the  unchanged 
model. 

Dr.  Allen  frankly  acknowledges  the  weakness  of  his  very  beautiful 
porcelain  by  giving  it  a  metallic  support.  The  dentist  knows  just 
what  he  is  using  here  (see  the  fourteenth  chapter),  and  can  exercise 
his  judgment  upon  the  suitability  of  the  work  *to  any  case  in  hand. 
The  few  dentists  who  make  porcelain  plates  are  more  reserved  in  com- 
municating their  knowledge.  Such  unprofessional  reserve  is  damaging 
to  dentistry  as  a  science ;  it  would  injure  it  also  as  an  art,  if  entire 
porcelain  dentures  had  a  strength  equal  to  their  beauty.  It  is  claimed 
by  some  makers  of  these  plates  that  their  formulas  give  a  porcelain 
which  is  very  strong,  yet  has  a  very  slight  shrinkage.  But  until  such 
formulas  are  made  known  to  the  profession,  and  an  opportunity  given 
to  test  them,  the  general  prejudice  against  the  porcelain  base  must 
continue  to  be  well  founded.  To  those  desirous  of  experimenting  in 
this  direction,  we  might  suggest  the  use  of  silicate  of  magnesia  and 


PORCELAIN    PLATES.  943 

lime  (asbestos)  and  coarsely  pulverized  porcelain  fragments,  as  perhaps 
lessening  the  shrinkage  of  the  mass. 

By  some  the  oi'dinary  dental  porcelain  paste  is  used,  making  pro- 
vision for  shrinkage  by  enlargement  of  the  model.  One  method  of 
enlargement  is  as  follows  :  With  a  fine  saw  divide  the  plaster  model 
by  a  cut  through  the  median  line  and  another  on  each  side  ;  separate 
these  four  sections  one-eighth  inch  and  fill  the  joints  with  plaster,  first 
saturating  them  with  water ;  then  cut  the  model  twice  at  right  angles 
to  the  first  lines,  and  fill  with  plaster  as  before.  If  the  back  of  model 
is  perfectly  level,  and  the  work  is  very  carefully  done,  we  shall  have 
a  tolerably  accurate  enlargement  of  about  one-fifth.  Make  a  plaster 
matrix  over  this,  and  into  it  pour  a  furnace  model,  composed  of 
three  or  four  parts  asbestos  or  sand  to  one  of  plaster.  On  this,  mould 
and  carve  and  bake  the  plate  and  teeth ;  else  transfer  the  plate  to  a 
pile  of  coarse  silex,  so  arranged  as  to  give  it  as  much  support  as 
possible  during  the  firing. 

Teeth  and  plate  are  sometimes  carved  out  of  the  same  mass  on  the 
enlarged  model ;  or  blocks  may  be  made  as  already  described,  then 
transferred  and  united  to  a  porcelain  plate  on  this  model.  Sometimes 
the  teeth  from  the  depots  are  arranged  in  the  porcelain  paste,  and 
gum  enamel  applied  around  the  teeth  and  over  the  plate.  Unlike 
continuous-gum  work,  the  teeth  are  not  attached  to  any  unyielding 
plate;  hence  they  are  liable  to  change  position  by  the  contraction  of 
the  plate  during  firing. 

We  cannot  more  appropriately  close  this  chapter  on  dental  porce- 
lain than  by  quoting  some  remarks  of  the  great  English  ceramic  manu- 
facturer, Josiah  Wedgewood,  applicable  to  the  art  which  he  did  so  much 
to  elevate.  They  have  a  significance  beyond  ceramic  art ;  and  convey, 
in  this  lesson  of  the  past,  a  warning  to  those  who  may,  perhaps  uncon- 
sciously, be  dishonoring  the  profession  of  their  choice. 

"All  works  of  taste  must  bear  a  price  in  proportion  to  the  skill, 
taste,  time,  expense  and  risk  attending  their  invention  and  manu- 
facture. Those  things  called  dear  are,  when  justly  estimated,  the 
cheapest ;  they  are  attended  with  much  less  profit  to  the  artist  than 
those  which  everybody  calls  cheap.  Beautiful  forms  and  compositions 
are  not  made  by  chance,  nor  can  they  ever,  in  any  material,  be  made 
at  small  expense.  A  competition  for  cheapness,  and  not  for  excellence 
of  workmanship,  is  the  most  frequent  and  certain  cause  of  the  rapid 
decay  and  entire  destruction  of  arts  and  manufactures." 


944  MECHANICS. 


CHAPTER  XVir. 

DEFECTS   OF    THE   PALATINE   ORGANS. 

ONE  of  the  most  distressing  deformities  to  which  the  human  frame 
is  liable,  is  found  in  that  defective  condition  of  the  palatine  organs 
which  is  known  to  surgeons  by  the  name  of  Cleft  Palate.  The  unfor- 
tunate sufferer  is  compelled,  in  a  great  measure,  to  be  an  alien  among 
his  fellow  creatures ;  an  object  of  compassion  to  the  considerate,  he  is 
often  made  painfully  conscious  of  notice  by  the  heartless  crowd  ;  and 
were  he  gifted  with  the  power  and  eloquence  of  a  Demosthenes,  or  with 
the  garrulousness  of  a  Cleon,  he  could  make  little  more  use  of  his  en- 
dowments than  a  mute.  Fortunately,  this  painful  defect  is  no  longer 
to  be  reckoned  as  one  of  the  opprobria  medicorum ;  for  both  surgical 
and  mechanical  means  are  now  at  hand  by  which  the  imperfection  may 
at  least  be  remedied,  and  often  cured. 

Defects  of  the  palatine  organs  may  be  divided  into  two  classes,  viz. : 
Accidental  and  Congenital.  The  first  includes  all  loss  of  substance  in 
either  hard  or  soft  palates,  whether  occasioned  by  disease  or  otherwise. 
Such  defects  are  not  uniform  in  locality,  nor  in  extent ;  consisting 
sometimes  of  simple  perforations,  and  at  others  involving  the  destruc- 
tion of  the  velum,  a  considerable  portion  of  the  os  palati,  the  vomer 
and  turbinated  bones,  and  the  loss  of  a  greater  or  less  number  of  the 
teeth.  The  second  class  includes  all  malformations,  from  the  sitflple 
bifurcation  of  the  uvula  to  an  opening  through  the  velum,  palatine  and 
maxillary  bones,  and  a  fissure  of  the  upper  lip ;  thus  uniting  the  nasal 
passages  with  the  oral  cavity  throughout  their  entire  extent. 

These  malformations  are  quite  similar  in  character,  but  not  uniform 
in  extent.  They  may  be  said  to  begin  with  the  uvula,  and  in  the 
uvula  and  velum  always  occupy  the  median  line ;  but  as  the  defect 
progresses  anteriorly,  it  may  deflect  to  one  side  or  the  other  of  the 
vomer  and,  following  the  nasal  passage,  divide  the  lip,  leaving  the 
vomer  articulated  with  the  palatine  bone  upon  one  side ;  while  in 
other  cases,  the  deformity  seems  to  follow  the  median  line,  and  thus 
involves  both  nasal  passages,  terminating  in  a  double  fissure  of 
the  lip. 

Congenital  defects  of  the  palate  are  usually  accompanied  by  more  or 
less  deformity  of  the  sides  of  the  alveolar  arch,  and  of  the  teeth.  Some- 
times the  sides  of  the  alveolar  ridge  are  forced  too  far  apart,  and  at 
other  times  they  are  too  near  each  other ;  while  the  teeth  are  either  too 


DEFECTS   OF   THE   PALATINE   ORGANS.  945 

large  or  too  small,  and  are  generally  of  a  soft  texture,  with  imperfectly 
developed  roots. 

Want  of  coaptation,  resulting  from  defective  formation  in  the  pala- 
tine plates  of  the  maxillary  and  palate  bones,  is  the  cause  of  congenital 
deficiencies  of  the  parts  in  question.  In  the  human  embryo  of  about 
the  third  week,  the  development  of  the  /ace  is  clearly  in  progress. 
Five  tubercles  bud  out  from  the  front  of  the  cephalic  mass,  of  which 
the  middle  one  (which  is  double)  is  directed  vertically  downward,  and 
bears  the  appellation  incisive  tubercle;  because  the  inter-maxillary 
bones,  destined  to  hold  the  superior  incisor  teeth  exclusively,  are  de- 
veloped in  it.  On  either  side  is  the  tubercle,  or  rudiment  of  an  upper 
maxillary  bone,  which  is  separated  from  its  fellow  by  a  wide  interval, 
and  from  the  neighboring  incisive  process  by  a  fissure.  The  fourth 
and  fifth  tubercles,  also  separated  in  front,  form  by  their  subsequent 
union  in  the  median  line,  the  inferior  maxillary  bone.  At  the  same 
period,  the  palate  begins  to  be  formed  by  the  approach  toward  the 
median  line  of  two  horizontal  plates,  or  processes,  springing  from  the 
maxillary  process  on  either  side.  (See  Development  of  Bones  of  Head 
and  Face.) 

If  now  development  proceed  regularly  and  normally,  the  palate 
processes  of  the  superior  maxilla  meet  in  the 
median  line,  and  unite  with  the  blended 
intermaxillary  tubercles ;  while  the  vomer 
grows  downward  to  meet  the  palate  processes 
in  their  line  of  union.  The  upper  jaw,  after 
the  accomplishment  of  these  changes,  is  com- 
plete, and  the  formation  of  the  lip  and  pri- 
mary dental  groove  follows  in  due  course. 
But  it  sometimes  happens  that  the  superior 
maxillary  and  intermaxillary  processes  fail  to 
unite  with  each  other ;  whence  we  have  the 
malformation  known  as  harelip,  or  the  palate  plates  are  arrested  in 
their  growth,  and  permanent  fissure  of  the  palate  is  the  result.  Conse- 
quently, the  fissure  of  single  harelip  is  never  exactly  in  the  median 
line,  but  on  the  edge  of  the  intermaxillary  bone ;  whereas,  in  double 
harelip,  a  fissure  exists  on  each  side  of  this  bone,  in  which  the  four 
incisor  teeth  are  planted. 

Fissure  of  the  hard  palate  is  usually  a  little  lateral,  and  not  median, 
as  it  results  from  a  deficiency  of  one  or  other  of  the  palate  plates  of  the 
upper  maxillary  bone ;  and  it  is  frequently  associated  with  harelip 
and  fissure  of  the  upper  jaw. 

The  tubercles,  or  formative  processes  of  the  lower  jaw,  advance  and 
meet  in  the  median  line,  while  the  upper  maxillary  processes  are  still 
60 


946  MECHANICS. 

separate.  In  man  they  are  consolidated  into  a  single  piece ;  but  they 
remain  permanently  divided  in  many  of  the  lower  animals  by  a  median 
suture. 

The  principal  effects  resulting  from  an  absence  of  a  portion  of  the 
palatine  organs  are,  an  impairment  of  the  functions  of  mastication, 
deglutition  and  speech.  Distinct  utterance  is  sometimes  wholly  de- 
stroyed, and  mastication  and  deglutition  are  often  so  much  embarrassed 
as  to  be  performed  only  with  great  difficulty. 

These  effects  are  always  in  proportion  to  the  extent  of  the  separation 
or  deficiency  of  the  parts.  The  simple  act  of  triturating  the  food  may 
not  be  materially  impaired  by  the  absence  of  a  portion — however 
extensive — of  the  palatine  organs,  unless  the  natural  relations  of  the 
teeth  of  the  upper  and  lower  jaws  are  changed  ;  still,  the  process  is 
more  or  less  interfered  with,  as  substances  taken  into  the  mouth  cannot 
be  so  readily  managed  as  when  the  parts  are  in  their  natural  state. 
They  are  liable  to  escape  from  the  control  of  the  tongue,  and  pass  into 
the  cavity  of  the  nose. 

In  cases  of  congenital  defects  of  the  palate  and  velum,  it  is  difficult 
to  conceive  how  infants  manage  to  obtain  from  the  breast  of  the  mother 
or  nurse  the  food  necessary  for  their  subsistence ;  yet,  even  when  the 
anterior  part  of  the  alveolar  border  and  a  part  of  the  upper  lip  are 
wanting,  the  suggestions  of  natural  instinct  enable  them,  by  a  peculiar 
management  of  tongue  and  lips,  to  do  it.  The  expedient  resorted  to 
for  effecting  this  process  is  curious.  The  nipple,  instead  of  being 
seized  between  the  tongue,  upper  lip  and  gum,  is  taken  between  its 
lower  surface  and  the  under  \\-p  and  gum  ;  and  in  this  way  it  manages 
to  extract  the  nourishment  necessary  for  subsistence  and  growth.  The 
tongue  is  thus  made  to  close  the  opening  in  the  palate,  and  perform 
the  office  of  an  obturator.  By  contracting  the  lip  and  depressing  the 
tongue,  the  milk  is  drawn  from  the  breast  of  the  mother  or  nurse.  At 
this  young  and  tender  age  the  child  is  not  conscious  of  the  imperfec- 
tion of  its  palate ;  and  it  is  not  until  the  period  arrives  when  it  should 
begin  to  make  its  wants  known  by  words,  that  it  feels  the  importance 
of  the  function  of  speech,  and  begins  to  realize  the  misfortune  with 
which  it  is  afl|icted. 

As  the  child  arrives  at  this  period,  the  mechanism  of  sucking  is  per- 
fected, and  is*  ultimately  applied  to  the  mastication  of  solid  aliments. 
The  food,  when  chewed,  is  conveyed  between  the  tongue  and  movable 
floor  (which  serves  for  a  point  d'appui),  and  it  is  brought  back  between 
the  teeth.  Thus  it  is  that  the  complicated  operation  of  mastication 
and  deglutition  is  performed  without  the  alimentary  morsel  getting 
into  the  nose;  or,  if  this  does  sometimes  happen,  it  is  the  result  of 
accident.    But  in  cases  of  accidental  lesion  of  the  palate,  the  individual 


DEFECTS   OF   THE   PALATINE   ORGAXS.  947 

has  not  the  advantage  of  this  training  of  the  parts  during  early  in- 
fancy. Those  who  are  afflicted  with  accidental  lesions,  no  matter  what 
may  be  their  position  and  extent,  having  acquired  the  habit  of  eating 
by  placing  the  aliment  upon,  and  not  under,  the  tongue,  can  take  no 
nourishment  without  a  part  of  it  getting  into  the  nose.  When  to  this 
inconvenience  is  added  a  change  in  the  natural  relation  of  the  teeth  of 
the  two  jaws,  mastication  is  rendered  still  more  difficult  and  embar- 
rassing. When  this  is  the  case,  the  tubercles  of  the  teeth  of  one  jaw, 
instead  of  being  received  into  the  depressions  of  those  of  the  other, 
strike  upon  their  protuberances,  and  cannot  be  made  to  triturate  the 
food  in  as  thorough  and  perfect  a  manner  as  is  required  for  healthy  and 
easy  digestion.  Thus,  not  only  is  the  process  of  mastication  rendered 
imperfect,  but  it  is  also  more  tedious. 

The  process  of  deglutition  itself,  so  long  as  the  velum  and  uvula  are 
perfect,  is  not  materially  affected  by  a  simple  perforation  of  the  vault 
of  the  palate,  although  much  difficulty  may  be  experienced  in  convey- 
ing alimentary  and  fluid  substances  to  the  fauces  and  pharynx.  But 
when  this  curtain  is  cleft,  or  is  partially  or  wholly  wanting,  degluti- 
tion is  rendered  very  difficult ;  for,  by  the  contraction  of  the  muscles 
of  the  pharynx,  part  of  the  food  is  forced  up  into  the  nose.  The 
reason  of  this  will  appear  obvious,  when  we  take  into  consideration  the 
form  and  function  of  this  movable  appendage.  When  its  muscles  are 
relaxed,  it  forms  a  slightly  concave  curtain  ;  but  in  the  act  of  degluti- 
tion, the  muscles  contract,  raise  the  velum,  and  close  the  opening  from 
the  pharynx  into  the  posterior  nares.  By  this  valvular  arrangement 
alimentary  substances  and  fluids  are  prevented  from  escaping  into  the 
nose.  It  matters  not,  therefore,  whether  the  imperfection  of  the  \elum 
palati  be  the  result  of  accident  or  disease;  its  effects  upon  deglutition 
are  the  same.  In  proportion  as  the  lesion  or  deficiency  is  great,  will 
this  operation  be  rendered  difficult  and  embarrassing.  There  are  cases 
where,  in  consequence  of  an  imperfection  of  the  palate,  the  patient  can 
swallow  no  fluids  without  a  part  being  returned  by  the  nose.  To 
obviate  this  inconvenience,  the  head  is  thrown  sufficiently  far  back  to 
precipitate  them  into  the  oesophagus.  This  is  an  expedient  to  which 
many  thus  afiected  have  been  compelled  to  resort. 

Imperfection  of  speech  always  results  from  an  opening  in  the  palate ; 
it  gives  the  voice  a  nasal  twang,  and  renders  the  formation  of  some 
sounds  impossible.  The  loss  of  the  teeth,  to  a  less  extent,  is  productive 
of  the  same  efiect.  To  comprehend  fully  the  manner  in  which  a  lesion 
of  the  palate  may  afiect  the  utterance  of  speech,  it  will  be  necessary  to 
understand  the  agency  which  the  several  parts  of  the  mouth  have  in 
ihe  formation  of  articulate  sounds.  Speech  consists  in  the  sounds 
produced  by  the  organs  of  the  glottis  modified  by  the  organs  of  the 


948  MECHANICS. 

mouth.  The  modulation  of  the  voice,  that  is,  the  raising  or  lowering 
of  its  pitch,  is  accomplished  by  the  vocal  cords  of  the  glottis ;  but  the 
articulation  of  the  consonants  requires  the  cooperation  of  all  the  mov- 
able and  fixed  parts  of  the  mouth  and  pharynx,  palate,  tongue,  lip^, 
teeth  and  palatine  arch.  Hence,  if  any  of  these  be  defective  or  want- 
ing, the  power  of  forming  some  of  these  sounds  is  wholly  lost,  of  others 
very  much  impaired ;  hence,  also,  the  ability  to  sing  is  much  less  inter- 
fered with  than  the  power  of  distinct  speech.  The  tongue  has  a 
remarkable  power  of  adapting  itself  to  the  loss  of  teeth  and  of  some 
other  parts,  so  as  measurably  to  correct  the  effect  on  speech ;  but  the 
effect  of  the  loss  of  the  hard  or  soft  palate  upon  the  voice  cannot  be 
remedied  in  any  such  way. 

In  both  cases  (accidental  and  congenital)  the  faculty  of  distinct 
articulate  speech  is  seriously  impaired  by  defects  of  any  extent.  In 
ordinary  cases  of  congenital  deformity  in  an  adult,  deglutition  is  not 
materially  interfered  with.  The  patient,  having  never  known  any 
other  method  of  swallowing,  is  not  conscious  of  any  difficulty.  Acci- 
dental lesions,  however,  coming  generally  in  adult  life,  produce,  in 
this  respect,  very  great  inconvenience.  The  remedy  for  these  evils 
must  be  the  closing  of  the  abnormal  passage  by  some  means  which 
will  restore  to  the  deformed  organs  their  functions.  In  perforations 
of  the  hard  palate,  unless  of  extraordinary  extent,  the  method  is  very 
simple.  In  the  loss  of  the  soft  palate  by  disease  the  remedy  is  more 
difiicult,  and  in  extensive  congenital  deformity  still  more  complicated 
means  must  be  resorted  to. 

8TAPHYLORRAPHY. 

The  operation  which  is  resorted  to  in  the  treatment  of  fissured  palate 
is  known  by  the  name  of  Staphylorraphy,  a  word  of  Greek  derivation, 
signifying  suture  of  the  uvula.  It  is  an  operation  which  has  been 
perfectly  successful  in  many  instances,  although  there  are  numerous 
cases  which  will  derive  far  more  benefit  from  mechanical  assistance 
than  from  the  surgeon's  aid. 

In  considering  the  operation,  a  brief  sketch  will  be  given  of  the 
anatomy  of  the  parts  concerned  in  its  performance ;  this  will  be  fol- 
lowed by  a  description  of  the  various  kinds  of  clefts;  we  shall  then 
describe  the  means  adopted  by  different  surgeons  for  their  relief  or 
cure.  To  obtain  success  in  staphylorraphy,  the  first  care  must  be  to 
gain  a  practical  acquaintance  with  the  position  and  relation  of  the 
muscles  connected  with  the  palate  and  fauces ;  and  this  can  be  accom- 
plished best  by  laying  open  the  pharynx  from  behind,  for  thus  the 
posterior  surface  of  the  soft  palate  is  at  once  exposed  to  view.  We  shall 
find  that  this  structure  is  wholly  composed  of  muscular  tissue,  covered 


STAPHYLORRAPHY.  949 

with  a  layer  of  mucous  membrane  continuous  with  that  lining  the  hard 
palate. 

The  muscles  with  which  we  have  chiefly  to  do  are :  the  palato-glossi 
and  the  palato-pharyngei,  forming  the  anterior  and  the  posterior  pillars 
of  the  soft  palate  respectively ;  the  levatores  palati,  the  tensores  palati, 
and  the  azygos  uvulae. 

The  levator  palati  is  a  long,  rounded  muscle  lying  obliquely  on  the 
outer  side  of  the  posterior  opening  of  the  nares.  It  takes  its  origin 
from  the  petrous  portion  of  the  temporal  bone  and  from  the  cartilage 
of  the  Eustachian  tube,  and  then  descends  obliquely  downward  and 
inward,  its  fibres  spreading  out  over  the  posterior  surface  of  the  soft 
palate  until  they  meet  with  those  of  the  corresponding  muscle  on  the 
opposite  side. 

The  palato-glossus  is  a  very  small  muscle  arising  from  the  anterior 
surface  of  the  soft  palate  on  each  side  of  the  uvula,  whence  it  passes 
forward  and  outward  to  be  inserted  into  the  dorsum  of  the  tonsrue. 
thus  forming  the  anterior  pillar  of  the  fauces. 

The  palato-pharyngeus  is  separated  from  the  preceding  muscle  by  a 
space  in  which  the  tonsil  lies.  It  arises,  by  two  origins,  from  the  soft 
palate,  and  descending  outward  and  downward,  is  inserted  into  the 
posterior  border  of  the  thyroid  cartilage. 

The  tensor  palati  arises  from  three  points,  viz.:  first,  from  the  sca- 
phoid fossa,  at  the  base  of  the  internal  pterygoid  plate ;  secondly,  from 
the  cartilaginous  portion  of  the  Eustachian  tube ;  and  thirdly,  from 
the  spinous  process  of  the  sphenoid  bone ;  it  then  terminates  in  a  tendon 
which  winds  around  the  hamular  process,  which  may  be  plainly  dis- 
covered with  the  finger  about  half  an  inch  behind  the  tuberosity  of 
the  superior  maxilla ;  and  it  then  passes  horizontally  and  expands  into 
a  broad  aponeurosis  on  the  anterior  surface  of  the  soft  palate. 

The  azygos  uvulse  arises  from  the  posterior  nasal  spine  of  the  palate 
bone  and  from  the  aponeurosis  of  the  soft  palate,  and  descends  to  be 
inserted  into  the  uvula. 

Having  learned  the  attachment  of  these  muscles,  it  will  be  well  to 
consider  their  respective  actions  upon  the  palate,  in  order  more  clearly 
to  comprehend  their  relations  to  the  separated  portions  of  a  cleft  pal- 
ate. The  levatores  palati  slightly  raise  the  soft  palate  while  it  is  made 
tense  by  the  action  of  the  tensor  palati.  The  palato-pharyngei  con- 
tract, and  bring  the  two  sides  of  the  palate,  from  whence  their  fibres 
arise  in  close  contact,  together. 

The  action  of  these  muscles  show  what  an  important  part  they  must 
bear  in  regard  to  the  operation  of  staphylorraphy  ;  and  when  this  is  con- 
sidered in  detail,  it  will  be  seen  why  but  little  success  was  met  with,  until 
means  -were  found  to  render  muscular  action  of  the  parts  impossible. 


950  MECHANICS. 

The  deficiency  of  the  palate  varies  considerably,  from  a  mere  divi- 
sion of  the  uvula  to  a  gap  which  constitutes  a  hopeless  deformity. 
When  this  abnormal  state  is  limited  to  the  soft  palate,  the  cleft  is 
always  of  a  triangular  shape,  the  apex  being  above  and  the  base  below  ; 
but  when  the  soft  and  hard  structures  are  involved,  it  is  of  a  more  or 
less  quadrilateral  shape. 

We  shall  here  only  consider  those  cases  which  are  congenital  in  their 
origin,  merely  alluding  to  the  distinction  between  this  class  of  deform- 
ity and  that  kind  which  may  be  said  to  be  acquired,  or  is  accidental. 
In  congenital  cleft  the  fissure  is  generally  confined  to  the  median 
line  of  the  palate,  because  the  two  halves  have  not  united  at  that  part 
at  the  usual  period.  In  acquired  or  accidental  deformity,  lesions  are 
met  with  in  all  parts  of  the  palate,  to  the  right  or  left  of  the  median 
line,  and  are  usually  the  result  of  syphilitic  ulceration,  or  have  some 
traumatic  origin. 

Congenital  clefts  may  be  thus  classed  :  Firstly,  a  small,  triangular- 
shaped  fissure,  extending  through  the  uvula  and  the  posterior  portion 
of  the  velum  palati,  the  other  portion  of  the  palate  being  quite  intact 
and  sound.  Secondly,  the  whole  of  the  soft  palate  is  involved.  Thirdly, 
the  soft  palate  and  a  portion  of  the  palate  bone  is  deficient.  Fourthly, 
the  cleft  may  be  associated  with  abnormality  in  the  alveolar  process  of 
the  palate  bone,  and  even  with  harelip.  Fifthly,  openings  occur  in 
the  hard  palate,  the  soft  palate  being  unafiected.  These  separations 
may  be  very  narrow,  not  exceeding  a  few  lines  in  width,  or  the  gap 
may  be  such  that  mouth  and  nostril  seem  but  one. 

The  fissure  posteriorly  is  always  on  the  median  line ;  anteriorly,  it 
generally  deflects  to  one  side  or  the  other  of  the  nasal  septum,  passing 
als3  to  one  side  of  the  inter-maxillary  bone.  In  some  rare  cases  both 
nasal  passages  are  involved,  and  a  double  harelip  is  the  Consequence. 
The  effects  of  this  condition,  already  stated,  may  thus  be  briefly 
summed  up.  During  infancy  the  functions  of  suction  and  deglutition 
are  with  difficulty  performed,  and  at  a  later  stage  mastication  and 
articulation  are  much  impeded.  There  is  also  imperfect  control  over 
the  muscles  of  the  palate,  both  fluids  and  solids  are  liable  to  pass  into 
the  windpipe,  and  not  unfrequently  there  is  regurgitation  through  the 
nose.  The  speech  is  guttural  and  nasal,  often  so  indistinct  as  to  render 
it  almost  entirely  unintelligible,  and  the  patient  is  only  too  anxious  to 
grasp  at  any  chance  that  may  be  held  out,  as  being  likely  to  grant 
some  amelioration  of  his  condition. 

Various  methods  have  been  suggested  for  the  cure  of  this  deformity. 
Some  have  proposed  to  close  the  cleft  in  early  infancy,  by  means  of 
pressure  on  the  yielding  bones :  others  maintain  that  artificial  substi- 
tutes are  best  adapted  to  relieve  the  patient's  suff*ering  ;  while  others 


STAPIIYLORRAPHY. 


951 


as  strenuously  proclaim  the  knife  to  be  the  only  means  whereby  success 
may  be  attained. 

The  first  surgeon  who  directed  serious  attention  to  the  operation  was 
M.  Roux,  a  notable  French  surgeon,  who  performed  it  upon  a  young 
American  physician,  in  the  year  1825.  Velpeau  informs  us  that  M. 
Colombo,  another  Frenchman,  performed  the  operation  on  the  cadaver, 
in  1813,  being  probably  actuated  to  attempt  its  performance  by  read- 
ing the  successful  efforts  of  a  French  dentist  (Le  Mounier)  to  cure 
cleft  palate  by  surgical  procedure,  as  early  as  1764.  For  more  than 
fifty  years  after  this  date  the  operation  seems  to  have  been  forgotten, 
or  to  have  fallen  into  disuse,  until  it  was  revived  by  M.  Roux,  in  France, 
and  almost  simultaneously  by  Dr.  John  C.  Warren,  of  Boston,  each 
of  whom  seems  to  have  performed  the  operation  in  total  ignorance  of 
what  was  done  by  the  other. 


In  1827,  Dr.  Stevens,  of  New  York,  operated  with  success ;  in  the 
succeeding  year,  Dr.  Mettauer,  of  Virginia,  followed  in  tlie  footsteps  of 
his  confreres  in  the  profession,  and  embodied  his  experience  of  staphyl- 
orraphy  in  a  very  interesting  article  which  appeared  in  1837.  The  oper- 
ation also  attracted  attention  in  England,  where  we  believe  it  was 
performed  for  the  first  time  by  Mr.  Alcock,  in  1822.  Since  then  it  has 
become  one  of  the  most  frequent  operations  in  surgery,  and,  through 
the  suggestions  and  improvements  made  by  Hamilton  and  Dieffenbach, 
by  Fergusson,  Pollock,  and  Mason,  it  has  served  still  further  to  enhance 
the  benefits  which  it  is  the  privilege  of  the  surgeon's  art  to  extend  to 
all  mankind. 

The  operations  of  M.  Roux  and  Dr.  Warren  were  very  similar  in 


952 


MECHANICS. 


character,  and  we  think  that  equal  credit  must  be  extended  to  the 
Frenchman  and  to  the  American  for  the  revival  of  staphylorraphy  ; 
while  English  surgery  deserves  no  little  credit  for  the  suggestions  of 
men  like  Pollock  and  Fergusson,  which  have  contributed  so  much  to 
its  present  success. 

All  the  earlier  operations  of  staphylorraphy  consisted  in  paring  away 
the  edges  of  the  cleft,  and  then  bringing  them  in  contact,  by  means  of 
sutures,  until  union  was  effected.  The  various  stages  of  the  operation 
as  then  performed  are  sufficiently  illustrated  in  the  accompanying 
engravings,  the  successive  steps  being  taken  in  the  order  of  these 
drawings.  Many  modifications  of  this  plan  were  made  by  Warren, 
Mettauer,  Stevens,  Graefe,  and  others ;  but  Fergusson  introduced  a 


Fig.  716. 


new  principle  of  treatment  in  the  operation  Avhich  has  very  materially 
added  to  its  successful  results. 

We  have  alluded  to  the  use  of  the  muscles  composing  the  velum  of 
the  palate,  and  their  important  action  on  it,  and  to  Fergusson  must  be 
assigned  the  credit  of  being  the  first  to  realize  practically  the  fact  that 
muscular  action  was  the  most  frequent  cause  of  failure  of  the  opera- 
tion ;  and  he  proved  the  truth  of  his  conjecture  by  his  method  of 
removing  the  difficulty;  namely,  the  division  of  the  muscles  of  the 
palate,  thus  entirely  paralyzing  their  action. 

Prior  to  this  discovery.  Sir  Wm.  Fergusson  had  adopted  an  opera- 
tion somewhat  similar  to  Warren's  and  founded  on  that  of  Roux,  which 
was  performed  as  follows :  The  patient  was  placed  in  a  chair  with  a 
back  slightly  more  inclined  than  usual ;   his  head  being  then  well 


STAPHYLOREAPHY. 


953 


supported,  and  his  mouth  kept  open  by  means  of  a  gag,  the  edges 
of  the  fissured  palate  were  pared  from  above  downward,  with  a  curved 
bistoury.  Next  a  curved  needle,  with  a  movable  eye,  armed  with 
a  strong  silken  ligature,  was  passed  yio.  717. 

through  the  palate,  at  the  upper  angle 
of  the  wound,  at  a  distance  of  about 
a  line  from  the  fissure.  The  other 
edge  was  transfixed  in  a  similar 
manner.  Two  other  ligatures  were 
then  inserted  in  the  same  way,  the 
third  and  last  being  as  close  as  pos- 
sible to  the  extremity  of  the  wound. 
The  threads  were  then  seized  with 
the  fingers  and  tied,  being  very  care- 
ful to  avoid  pressure  of  the  knot  upon 
the  middle  of  the  wound.  This  earlier 
operation  of  Mr.  Fergusson,  which 
was  the  type  of  many  others  that  have 
been  proposed,  and  which  is  substan- 
tially the  same  as  that  illustrated  by  the  figures  before  referred  to, 
has  been  described,  in  order  that  the  improvement  in  the  modern 
operation  may  be  the  more  fully  appreciated,  when  it  is  subsequently 
described  at  length. 

Preparation  of  the  Patient. — Mr.  Hamilton  Cartwright,  of  the  Royal 
College  of  Surgeons,  London,  makes  the  following  suggestions  for  the 
preparation  of  the  patient.  Before  undertaking  the  operation  of 
staphylorraphy,  various  points  have  to  be  considered.  Firstly,  having 
decided  that  a  surgical  operation  will  be  of  more  benefit  to  the  patient 
than  mechanical  aid,  cognizance  must  be  taken  of  his  general  health  ; 
for  upon  its  good  condition  much  of  success  must  ultimately  depend. 
Should  the  patient  be  chlorotic  or  anaemic,  the  operation  must  be  post- 
poned until  after  a  proper  treatment.  A  healthy  regimen  must  be 
prescribed  ;  frequent  but  not  fatiguing  exercise  in  the  open  air  must 
be  insisted  upon,  and  tonics  must  be  given,  their  character  being  deter- 
mined by  the  patient's  diathesis.  Particular  care  must  be  shown  in 
cases  of  struma,  as  there  is  no  condition  in  which  the  parts  are  more 
unlikely  to  heal  favorably  than  in  this.  For  the  relief  of  this  condi- 
tion it  may  be  necessary  to  devote  great  attention  for  many  months. 
Sea  air  will  be  of  much  service,  while  its  effects  will  be  enhanced  by 
giving  a  course  of  iron.  Mr.  Cartwright  recommends  particularly  two 
chalybeate  preparations,  which  are  of  the  greatest  value  in  ansemia,  as 
well  as  in  that  diathesis  now  under  consideration.  They  are  the  syrup 
of  the  iodide  of  iron  and  the  syrup  of  the  hypophosphate  of  iron  and 


954  MECHANICS. 

manganese.  The  latter  acts  as  a  tonic  and  an  alterative;  at  the  same 
time  it  keeps  up  an  easy  action  upon  the  bowels;  indeed,  there  is  no 
medicine  which  he  has  found  more  rapidly  successful  in  improving 
those  weak  and  enfeebled  states  of  the  system  which  are  owing  to 
scrofula  or  to  an  impoverished  condition  of  the  blood.  Nothing  has 
more  conduced  to  bring  staphylorraphy  into  disrepute  than  a  disregard 
of  the  physical  condition  of  the  patient ;  good  health  is  the  sine  qua  non 
of  rapid  and  successful  union  of  the  parts. 

Having  suited  the  treatment  to  the  indications  of  the  case,  it  is  of  the 
utmost  importance  that  the  patient  be  educated,  so  to  speak,  to  assist 
the  surgeon  in  the  operation  which  he  is  about  to  undertake ;  for  the 
fauces  are  intensely  sensitive,  and  were  the  condition  of  the  parts  for- 
gotten, the  retchings  and  convulsive  movements  so  easily  induced  in 
them  would  probably  cause  a  failure  in  the  proposed  cure.  Various 
means  of  lessening  this  sensibility  have  been  suggested ;  some  have 
recommended  rough  fingering  of  the  parts  daily  ;  and  Dr.  Garretson 
proposes  to  occasionally  pass  a  tenaculum  through  the  parts  to  be 
operated  upon,  a  treatment  which  we  rather  think  would  make  the 
patient  more  fearful  than  ever  of  the  operation.  As  good  a  method 
as  any  proposed  is  to  enjoin  the  friends  of  the  patient,  or  the  patient 
himself,  if  old  enough,  to  irritate  the  fauces  with  the  feather  of  a  quill ; 
in  a  few  weeks  it  will  be  found  that  the  parts  will  become  tolerant  of 
almost  any  irritation.  The  same  results  may  be  obtained  by  wearing 
an  obturator  extending  far  back  over  the  palate ;  the  irritation  at  first 
produced  by  it  will  soon  disappear,  and  after  wearing  it  constantly  for 
a  few  weeks,  all  the  usual  symptoms  produced  by  interference  with  the 
fauces  will  have  passed  away. 

Mr.  Cartwright  proposes  another  method  of  treatment,  which  is  some- 
what novel,  but  most  successful  in  its  results.  It  has  been  found  that 
the  exhibition  of  the  bromide  of  potassium  tends  to  deaden  the  sensi- 
bility of  the  fauces  in  a  very  remarkable  manner,  and  thus  it  may  be- 
come a  most  useful  agent  preparatory  to  the  operation.  If  exhibited 
in  half-drachm  doses,  given  thrice  daily  for  two  or  three  weeks  prior 
to  the  period  decided  upon,  but  little  irritability  of  the  parts  will  be 
found  remaining ;  and  by  the  time  a  few  imaginary  operations  on  the 
parts  have  been  performed,  by  the  aid  of  such  harmless  instruments  as 
a  camel's-hair  brush  or  the  feather  of  a  quill,  the  patient  will  be  found 
in  a  fit  condition  to  be  operated  upon.  A  few  days  prior  to  the  time 
of  operating,  more  particular  attention  must  be  paid  to  the  condition 
of  the  patient.  Primarily,  he  must  be  well  nourished,  inasmuch  as  he 
will  be  forced  to  adopt  a  different  regimen  from  that  to  which  he  has 
been  accustomed  for  some  days.  His  diet  must  be  nutritious  without 
being  stimulating,  and  the  greatest  attention  must  be  given  to  the 


STAPHYLORRAPHY.  955 

regular  action  of  the  bowels,  and,  indeed,  in  all  cases  it  is  well  to  give 
a  mild  aperient  before  operating. 

The  patient  having  been  thus  prepared,  much  of  the  success  of  the 
operation  will  depend  upon  his  ability  to  remain  tranquil  during  its 
performance,  and  to  give  as  much  assistance  to  the  surgeon  as  may  lie 
in  his  power.  Thus  he  may  assist  the  operator  by  opening  his  mouth 
widely,  by  not  resisting  the  introduction  of  instruments,  and,  subse- 
quently, by  keeping  the  newly-connected  parts  as  quiet  as  possible  by 
restraining  the  movements  necessarily  induced  by  deglutition  or  by 
attempts  at  articulation.  It  will  thus  be  seen  why  the  operation  for 
cleft  palate  must  be  delayed  until  the  patient  is  old  enough  to  exercise 
control  over  his  movements.  The  best  period  is  from  nine  to  ten  years 
of  age,  although  Sir  Wm.  Fergusson  has  frequently  operated  much 
earlier,  with  complete  success. 

As  before  observed,  the  pioneers  who  cleared  the  way  for  the  success  ot 
staphylorraphy  were  Roux  and  Warren,  and  many  modifications  of  their 
plans  have  been  made  from  time  to  time  by  others ;  but  the  man  who  in- 
troduced a  new  era  in  the  history  of  the  operation  was  Sir  Wm.  Fergus- 
son,  of  London,  who  has  rendered  it  most  perfect  in  allits  details.  This 
credit  being  generally  conceded  to  him,  we  shall  describe  his  mode  of 
operating  as  the  type  of  operations  generally. performed  in  modern  days. 

Warren  divided  the  pillars  of  the  fauces  empirically,  with  a  view, 
as  he  states,  of  relieving  the  tension  of  the  parts ;  but  nowhere  do  we 
find  that  he  speaks  specifically  of  dividing  the  muscles  contained  in 
them  ;  it  remained  for  Mr.  Fergusson  to  point  out  that  muscular  action 
was  the  great  cause  of  failure  in  most  cases,  and  he  practically  proved 
the  truth  of  his  conjecture  by  resorting  to  the  operation  of  myotomy, 
dividing  the  muscles  of  the  palate,  and  thus  paralyzing  their  move- 
ments. He  found  that  the  tension  on  the  line  of  union  was  principally 
exercised  by  the  levator  palati  and  by  the  levator  pharyngeus,  and  he 
then  proposed  the  following  operation  : — 

Sir  Win.  Fergusson' s  Operation.  —  Mr.  Cartwright  describes  Mr. 
Fergusson's  operation  as  follows:  He  first  divides,  the  muscles  of  the 
palate  by  passing  a  curved  knife  around  between  the  velum  palati  and 
the  end  of  the  Eustachian  tube,  thus  at  once  dividing  the  levator  palati. 
In  the  second  stage  he  seizes  the  uvula,  thus  bringing  forward  the  pos- 
terior pillar  of  the  fauces,  which  is  snipped  across  with  round-pointed 
scissors,  so  as  to  divide  the  fibres  of  the  palato-pharyngeus  muscle ; 
should  it  be  deemed  necessary  to  do  so,  the  anterior  pillar  may  be  divided 
at  the  same  time,  so  as  to  sever  the  palato-glossus,  though  Sir  William 
lays  no  stress  upon  the  necessity  of  doing  so.  Next,  the  uvula  is  again 
seized,  with  a  view  of  extending  the  palate  so  that  the  edges  of  the 
fissure  may  be  pared  away ;  this  is  accomplished  with  a  narrow  bis- 


956  MECHANICS. 

toury  from  behind  forward,  on  either  side  alternately,  the  angle  of 
union  being  left  for  subsequent  removal.  A  few  moments  then  are 
granted  to  the  patient  to  recover,  and  he  is  permitted  to  swallow  a  few 
small  pieces  of  ice,  with  the  double  view  of  refreshing  him  and  of 
staunching  the  bleeding.  When  this  has  sufficiently  ceased,  it  is  time 
to  introduce  the  sutures,  and  this  is  done  by  means  of  a  nsevus-needle, 
armed  with  a  silken  ligature,  the  needle  being  introduced  about  a 
quarter  of  an  inch  from  the  edge  of  the  fissure.  Next,  the  extremity 
of  the  thread  is  pulled  out  by  means  of  forceps,  and  another  ligature 
is  passed  in  like  manner,  until  the  desired  number  of  stitches  is 
attained.  The  extremities  must  then  be  tied  loosely,  so  as  just  to  keep 
the  parts  in  apposition,  and  no  more;  after  which  the  patient  is. put 
to  bed,  every  care  being  taken  to  avoid  all  motion  of  the  palate.  He 
should  take  nothing  but  nourishing  liquid  food  for  a  few  days,  and  must 
be  particularly  enjoined  to  abstain  from  all  movements  involving  action 
of  the  muscles  engaged  in  deglutition,  such  as  swallowing,  coughing, 
sneezing,  and  the  like,  which  would  much  endanger  the  success  of  the 
operation.  The  next  stage  consists  in  the  removal  of  the  stitches  ;  this 
need  not  be  done,  too  soon,  provided  they  produce  no  irritation  ;  indeed, 
they  may  remain  until  union  is  perfect.  The  general  time  for  their 
removal  is  about  the  seventh  or  eighth  day,  although  Fergusson  often 
removes  them  on  the  third  or  fourth. 

Mr.  G.  Pollock  has  introduced  the  following  modifications  in  the 
performance  of  this  operation  :  Instead  of  dividing  the  muscle  with  a 
curved  knife  from  behind,  according  to  the  method  we  have  just 
described,  Mr.  Pollock  passes  a  ligature  through  the  soft  palate,  so  as 
to  contract  and  draw  it  forward,  and  he  then  pushes  a  narrow-bladed 
knife  through  it,  a  little  to  the  inner  side  of  the  hamular  process  of  the 
pterygoid  plate  of  the  sphenoid  bone,  which  may  be  plainly  discovered 
by  passing  the  finger  along  the  roof  of  the  mouth  to  a  distance  a  little 
posterior  to  the  tuberosity  of  the  sujjerior  maxilla.  By  raising  the 
hand,  and  so  depressing  the  point  of  the  scalpel,  he  most  effectively, 
and  in  a  very  simple  manner,  divides  the  muscle.  The  parts  having 
healed,  the  patient  must  be  impressed  with  the  necessity  of  practicing 
himself  frequently  in  elocution,  telling  him  that  his  success  in  articu- 
lation will  depend  upon  himself  alone.  Constant,  patient,  persevering 
effort  will  be  necessary,  and  the  end  to  be  attained  must  be  sought  by 
distinctly  articulating  every  syllable  of  every  word  which  he  may  be 
called  upon  to  utter.  It  is  a  good  exercise  to  read  a  portion  of  some 
good  author  each  day  with  a  friend,  who  will  assume  the  role  of  school- 
master for  the  time  being,  permitting  no  word  to  be  indistinctly  uttered 
or  slurred  over,  and  requiring  each  syllable  to  be  correctly  and  sepa- 
rately pronounced. 


8TA  PHYLORRAPH  Y. 


957 


Fissure  of  the  hard  palate,  simple  or  connected  with  a  fissure  of 
the  soft.  Various  means  of  closure  have  been  proposed.  Dr.  Warren 
dissects  the  mucous  membrane  from  the  bone  on  either  side,  carrying 
his  knife  sufficiently  forward  toward  the  alveolar  border  to  form  a  flap 
broad  enough  to  meet  a  like  one  from  the  opposing  side,  along  the 
median  line.  When  the  fissure  is  so  wide  as  to  prevent  the  margins 
being  brought  together,  Dr.  Mettauer,  of  Virginia,  recommends  making 
several  lateral  incisions  through  the  mucous  membrane,  with  a  view 
of  permitting  the  edges  to  be  brought  into  close  apposition.  Dr.  Mutter, 
of  Philadelphia,  who  was  very  successful  in  the  operation,  also  had  re- 
course to  the  longitudinal  incision  (as  shown  by  Fig.  718),  which  was 
first  proposed  by  Dieffenbach,  with  the  most  happy  results.  Dr.  War- 
ren's operation  has  been  introduced  into  England  by  Mr.  Pollock,  who, 


Fig.  718. 


Fig.  719. 


with  his  peculiarly  constructed  instruments,  proceeds  as  follows  :  He 
makes  an  incision  along  the  edge  of  the  cleft  at  the  juncture  of  the 
nasal  and  palatal  mucous  membrane.  The  soft  covering  of  the  hard 
palate  is  carefully  dissected  or  scraped  from  the  bones  with  curved 
knives,  great  care  being  taken  that  the  mucous  membrane  and  its 
subjacent  fibro-cellular  tissue  are  not  perforated.  When  this  has 
been  well  loosened  on  either  side,  it  will  be  found  to  hang  down 
like  a  curtain  from  the  vault  of  the  mouth,  the  two  parts  coming 
into  apposition  along  the  median  line,  or  possibly  overlapping.  The 
edges,  being  then  smoothly  pared,  are  brought  together  by  means  of 
a  few  points  of  suture  introduced  in  the  ordinary  way,  and  without 
any  dragging.  Where  the  hole  is  not  very  large.  Dr.  Pancoast's  inge- 
nious operation  of  staphyloplasty  maybe  performed,  in  which  he  raises 


958  MECHANICS. 

two  flaps  of  mucous  membrane  from  the  bone  on  either  side,  and  then 
reflecting  them  across  the  chasm,  their  edges  are  brought  together  by 
suture  in  the  usual  manner,  a  plan  which  is  so  perfectly  exhibited  in 
Fig.  719,  that  we  do  not  deem  any  further  description  necessary. 
Recently,  M.  Langenbeck  has  suggested  another  operation,  in  which  he 
proposes  to  dissect  the  mucous  membrane,  together  with  the  peri- 
osteum, from  the  surface  of  the  bone  prior  to  bringing  the  opposed 
surfaces  of  the  cleft  in  apposition  ;  and  the  advantage  claimed  by 
him  for  this,  which  he  considers  to  be  a  novel  method  of  procedure,  is 
that  the  chasm  is  obliterated,  not  merely  by  soft  tissue,  but  by  bone, 
which  is  formed  from  the  periosteum  thus  loosened  from  contact 
with  the  surface  of  the  hard  palate.  If  this  theory  be  correct,  we 
cannot  out  think  that  Dr.  Warren  and  Mr.  Pollock  must  have  met 
with  like  results ;  although  it  is  remarkable  that  they  seem  to  have 
been  unconscious  of  the  great  advances  they  had  thus  made  in  the 
treatment  of  cleft  palate,  by  the  operation  which  the  one  proposed  and 
the  other  carried  out.  We  deem  it  impossible  that  Warren  should 
have  merely  raised  the  mucous  membrane  without  the  periosteum  at- 
tached to  it — a  dissection  so  difficult,  that  we  could  excuse  the  ablest 
surgeon  for  not  accomplishing  such  a  separation,  when  operating  on 
the  living  subject,  without  lesion  of  the  mucous  tissue ;  and  until  an 
autopsy  reveals  to  us  that  real  osseous  tissue  has  filled  up  the  breach  in 
the  continuity  of  the  palate  bone,  we  must  confess  that  we  shall  remain 
skeptical  as  to  the  results  now  claimed  by  Herr  Langenbeck  and  others 
for  their  revival  of  Dr.  Warren's  old  operation. 

There  is  one  other  treatment  which  we  have  mentioned,  and  to  which 
we  must  make  a  short  allusion,  and  that  is  the  method  of  closing  fissure 
of  the  hard  palate  by  means  of  pressure.  Velpeau  proposed  to  take 
advantage  of  the  yielding  character  of  young  bone,  by  adopting 
mechanical  means  which  would  bring  the  parts  separated  into  closer 
or  even  perfect  coaptation ;  this  idea  of  his  has  recently  been  more 
fully  worked  out  by  more  modern  experimentalists,  who  speak  highly 
of  the  success  which  has  crowned  their  efforts.  The  method  of  cure 
may  be  thus  briefly  described  :  A  clamp  or  compressor,  with  pads 
arranged  according  to  the  exigencies  of  the  case,  is  applied  on  either 
side  of  the  alveolar  arch ;  the  edges  of  the  fissure  and  of  the  bone 
having  been  pared  away,  the  action  of  a  screw  is  brought  to  bear  upon 
the  instrument,  until  the  soft  and  pliant  bones  are  brought  together. 
That  there  are  grave  disadvantages  attendant  on  this  mode  of  treat- 
ment cannot  fail  to  appear  to  every  dentist.  Firstly,  the  alveoli  of 
the  superior  maxilla  are  thrown  within  those  of  the  alveolar  border  of 
the  inferior  maxillary  bone,  thus  laying  the  foundation  of  serious  de- 
formity in  after-life.     Secondly,  the  germs  of  the  teeth  might  be  so 


STAPHYLOERAPHY.  959 

affected  as  to  induce  subsequent  irregularity  and  malposition.  Thirdly, 
there  is  danger  of  inflammation  being  excited,  while  the  delicate 
physique  of  the  young  child  runs  great  risk  of  being  affected  inju- 
riously by  the  irritation  resulting  from  constant  wearing  of  such  an 
instrument  as  that  described.  Lastly,  we  must  consider  the  chance  of 
fracture  by  exercising  too  much  compressive  power  upon  the  bones. 
This  hazard  is  acknowledged  by  those  who  advocate  the  proposed  oper- 
ation of  Velpeau ;  but  they  excuse  themselves  by  urging  that  even 
should  fracture  occur  it  would  be  of  little  consequence,  inasmuch  as 
the  injured  parts  are  kept  in  splints,  and  that,  therefore,  the  treatment 
which  would  be  correct  in  the  one  case  is  already  provided  for  the 
other.  It  is  to  be  feared  that  this  admission  will  rather  deter  others 
from  attemping  an  operation  in  which  much  evil  may  be  done  for  an 
uncertain  possible  future  good.  The  fact  is  more  and  more  acknowl- 
edged in  the  humane  surgery  of  the  present  day,  that  the  gentler  the 
means,  if  equal  to  the  end  proposed,  the  more  entitled  is  any  treatment 
to  recognition  and  to  praise. 

In  the  usual  operation  of  staphylorraphy  certain  muscles  most  im- 
portant to  speech  have  to  be  divided  ;  and  it  is  upon  this  very  division 
of  them  that  its  success,  in  an  operative  point  of  view,  so  much  de- 
pends, while  it  is  an  important  question,  whether  the  muscles  are  not 
thus,  in  spite  of  their  reunion,  to  a  certain  extent  deprived  of  power  ; 
and  this  we  believe  to  be  the  reason  why  articulation  is  often  so  little 
improved  after  the  successful  performance  of  the  operation  in  question. 
Hence  we  propose  that  surgical  and  mechanical  skill  should  combine 
to  produce  more  perfect  results  in  the  treatment  of  fissured  palate. 
We  have  been  led  to  make  this  proposition  by  the  success  Avhich  has 
attended  our  efforts,  in  cases  where  surgery  has  been  but  partially  suc- 
cessful in  her  attempts  to  secure  perfect  union  and  coaptation  of  the 
opposing  edges  of  the  cleft,  thus  leaving  a  gap  in  the  anterior  portion 
of  the  original  fissure,  while  the  posterior  parts  are  well  united.  .  The 
operation  which  we  suggest  is  to  pare  the  edges  of  the  halves  of  the 
bifurcated  uvula  and  the  posterior  portion  of  the  soft  palate  nearest  to 
them,  and  to  bring  about  the  union  of  these  parts  in  the  usual  manner, 
by  means  of  suture.  Union  having  been  effected,  the  deficiency  in 
the  anterior  portion  of  the  palate  is  to  be  filled  by  means  of  an  arti- 
ficial velum ;  the  artificial  velum  at  the  same  time  extending  backward 
and  nearly  filling  the  pharynx.  The  advantages  of  this  combined 
operation  are  very  manifest;  for  the  muscles,  being  uninjured,  their 
action  is  nearly  normal,  and  the  great  objection  of  bringing  about  a 
too  tense  condition  of  the  newly-united  palate  is  avoided  ;  this  being 
another  of  the  causes  which  prevent  great  improvement  of  articulation 
'as  a  result  of  staphylorraphy.     Now  in  the  partial  operation  just  de- 


960  MECHANICS. 

scribed,  these  disadvantages  are  at  once  removed,  and  the  gap  which 
still  remains  after  the  reunion  of  the  uvula,  being  filled  up  by  the  arti- 
ficial palate  attached  to  an  obturator,  the  muscles  still  have  their 
normal  play,  and  the  palatine  deficiency  is  better  supplied  than  by  the 
natural  union  of  the  separated  edges  of  the  cleft.  The  best  results 
have  been  obtained  by  this  most  simple  means  of  action.  Figs.  733 
and  735,  being  illustrations  of  cases  occurring  in  the  writer's  practice, 
show  very  forcibly  the  manner  of  the  proposed  treatment,  Fig.  735 
being  an  especially  interesting  case,  because  the  operation  of  staphy- 
lorraphy,  surgically  considered,  had  been  most  successfully  performed, 
but  articulation  seemed  but  little  improved.  The  patient  was  willing 
to  be  the  subject  of  an  experiment,  and  the  anterior  portion  of  the 
reunited  cleft  was  opened  up  again,  and  a  vefum,  with  an  obturator, 
introduced  in  the  space  thus  created.  The  results  were  eminently  sat- 
isfactory; the  tension  of  the  soft  parts  was  at  once  relieved  by  this 
division,  and  after  a  little  practice  the  patient  spoke  as  she  had  never 
spoken  before. 

There  are  many  cases  of  abnormality  in  the  os  palati  which  can  only 
be  relieved  by  mechanical  appliances,  and  this  relief  can  be  afforded 
in  a  most  satisfactory  manner  ;  no  more  inconvenience  being  felt  by  the 
patient  than  he  would  experience  in  wearing  an  artificial  denture,  with 
which  the  false  palate  could  be  connected,  were  it  necessary  to  do  so. 
Artificial  aid  has  been  several  times  alluded  to  in  reference  to  the 
operation  of  staphylorraphy,  and,  indeed,  it  is  still  an  open  question 
whether,  in  a  large  number  of  cases,  the  greatest  relief  is  not  afforded 
by  mechanical  appliances.  The  surgeon's  only  desire  should  be  to 
recommend  that  plan  of  treatment  which  he  considers  will  ultinaately 
render  the  greatest  service  to  his  patient.  Undoubtedly,  the  operations 
which  have  been  described  are  often,  as  far  as  mere  union  is  concerned, 
ra')St  satisfactory  in  their  results;  but  there  are  other  considerations 
besides  these.  Naturally,  the  chief  desire  of  the  patient  is  to  take  a 
footing  in  society  on  equal  terms  with  other  men ;  and  there  are  no 
means  which  will  enable  him  to  do  so,  unless  they  can  restore  to  him 
his  lost  or  impaired  power  of  speech — that  divine  gift  which  places  man 
so  immeasurably  above  the  brute  creation.  This  has  been  almost  lost 
in  many  cases  of  cleft  palate  ;  and  it  is  the  great  object  of  treatment 
to  put  the  sufferer  in  a  way  of  uttering  his  thoughts  in  plainly-spoken 
words,  like  those  around  him  ;  whatever  means  are  best  calculated  to 
bestow  this  inestimable  benefit,  are  those  which  the  conscientious  sur- 
geon ought  to  select. 

There  are  certain  cases  where  the  opening  is  not  large,  and  as  there 
is  little  tension  of  the  parts,  the  opposite  sides  come  together  in  close 
proximity  ;  staphylorrhaphy  may  here  be  performed  with  good  results, 


OBTURATORS   AND    ARTIFICIAL    PALATES.  961 

for  it  must  be  recollected  that  it  is  always  a  desideratum  to  avoid  the 
presence  of  foreign  substance  as  a  substitute  for  natural  tissues,  if  these 
are  equally  effective.  Allusion  has  been  made  to  the  liability  to  injury 
of  the  parts  by  a  division  of  the  muscles.  Where  an  artificial  palate  is 
used,  the  muscles  are  unimpaired  ;  and  we  have  heard  persons,  who, 
when  without  the  instrument  could  not  be  understood,  speak  fluently 
and  distinctly  the  moment  they  introduced  it  into  their  mouths.  So  far 
as  the  discomforts  of  wearing  such  an  apparatus  are  concerned,  after  a 
short  time  the  wearers  become  entirely  unconscious  that  they  are 
wearing  anything  artificial. 

OBTURATORS   AND   ARTIFICIAL   PALATES. 

We  have  classified  palatine  defects  as  accidental  and  congenital ;  we 
shall  also  classify  the  appliances  used  for  their  remedy.  The  term 
ohturator  will  be  used  for  all  instruments  intended  to  stop  or  close 
all  those  openings  in  the  hard  or  soft  palate  which  have  a  complete 
boundary.  Appliances  made  to  supply  the  loss  of  the  posterior  soft 
palate,  whether  accidental  or  congenital,  will  be  called  artificial  vela 
or  artificial  palates. 

Any  unnatural  opening  between  the  oral  and  nasal  cavities  which 
will  permit  the  free  passage  of  the  breath  will  impair  articulation. 
Any  appliance  which  will  close  such  passage,  and  can  be  worn  without 
inconvenience,  will  restore  articulation.*  Obturators  were  formerly 
made  of  metallic  plate,  gold  or  silver  being  most  commonly  employed, 
and  many  very  ingenious  pieces  of  mechanism  were  the  result  of  such 
efforts  ;  but  latterly,  vulcanized  rubber  has  almost  entirely  superseded 
the  use  of  metals.  Vulcanite  has  been  found  preferable  to  metals, 
being  much  lighter  and  much  more  easily  formed  and  adapted,  partic- 
ularly when  of  peculiar  shape. 

According  to  Guillemeau,  obturators  were  employed  by  the  Greek 
physicians ;  but  it  is  to  that  celebrated  French  surgeon,  Ambrose  Pare, 
that  we  are  indebted  for  the  first  description  of  an  appliance  of  this 
sort.  This  author  has  furnished  an  engraving  of  an  obturator  which 
he  had  constructed  in  1585,  consisting  of  a  metallic  plate,  probably  of 
silver  or  gold,  fitted  into  an  opening  in  the  vault  of  the  palate.  It 
was  held  up  by  means  of  a  piece  of  sponge,  fastened  to  a  screw  in  an 
upright  attached  to  the  upper  surface  of  the  plate.  The  employment 
of  sponge,  however,  was  found  to  be  objectionable,  as  the  secretions  of 
the  nasal  cavities,  which  it  absorbed,  soon  became  insufferably  offen- 

*  The  student  will  bear  in  mind  that  no  cognizance  is  here  taken  of  openings 
similar  to  those  described  in  cases  of  congenital  fissure,  where  the  surgeon  has 
united  the  soft  palate,  and  left  an  opening  through  the  hard  palate  to  be  covere 
by  an  obturator. 

6i 


962  MECHANICS. 

sive ;  notwithstanding  which,  it  continued  to  be  used  for  a  long  time. 
Ultimately,  however,  it  was  superseded  by  an  obturator  invented  by 
Fauchard.  This  was  held  up  by  means  of  wings,  which  turned  on  a 
pivot.  Both  of  these  obturators,  however,  exerted  a  hurtful  influence 
upon  the  surrounding  parts,  as  the  pressure  produced  by  the  sponge 
and  wings  caused  them  to  be  gradually  destroyed,  and  thus  augmented 
the  evil  they  were  designed  to  remedy  ;  consequently,  their  use  has 
been  wholly  abandoned.  We  do  not,  therefore,  deem  it  necessary  to 
give  a  description  of  either.  We  will,  however,  quote  a  passage  from 
Bourdet  upon  the  subject.  In  alluding  to  the  impropriety  of  having 
recourse  to  any  appliance  which  has  a  tendency  to  counteract  the  cura- 
tive efforts  of  nature,  he  says :  "  Before  considering  the  cicatrized  per- 
forations of  the  palate  as  being  of  a  nature  incapable  of  diminishing 
in  diameter,  practitioners  should  satisfy  themselves,  thoroughly  and 
beyond  doubt,  that  such  is  the  case.  We  do  not  think  that  this  con- 
dition of  permanency  can  exist,  for  positive  facts  attest  the  contrary ; 
and  as  holes  made  in  the  cranium  with  the  trepan  close  almost  entirely, 
in  like  manner  those  of  the  palate  constantly  diminish."  Numerous 
examples  might  be  adduced,  if  it  were  necessary,  to  prove  the  impro- 
priety of  sustaining  an  obturator  by  any  fixtures  which  act  upon  the 
lateral  parts,  as  they  necessarily  tend  to  increase  the  dimensions  of  the 
opening  in  the  palate. 

Where  atmospheric  pressure  cannot  be  obtained,  and  there  are  no 
teeth  for  clasping,  the  use  of  spiral  springs,  attached  to  a  partial  lower 
piece  or  to  caps  placed  over  the  lower  molars,  would  be  preferable  to 
this  very  objectionable  prominence  on  the  upper  surface  of  obturators. 
It  is  of  the  greatest  importance  that  an  artificial  palate  or  obturator 
should  be  executed  in  the  most  perfect  manner,  and  be  made  to  fit 
accurately  to  all  the  parts  with  which  it  is  to  be  in  contact,  so  that  it 
may  not  produce  the  slightest  irritation  or  exert  undue  pressure  upon 
any  of  the  surrounding  parts.  As  in  the  case  of  the  application  of  a 
dental  substitute,  the  piece  should  not  be  applied  while  any  of  the 
teeth,  especially  those  of  the  upper  jaw,  are  in  an  unhealthy  condition. 
The  gums  and  sockets  of  the  teeth  should  also  be  free  from  disease. 

With  a  view  of  obviating  the  objections  which  have  been  mentioned 
as  existing  to  the  obturators  of  Pare  and  Fauchard,  Bourdet  proposed 
to  employ  simply  a  metallic  plate,  fitted  to  the  vault  of  the  palate  and 
large  enough  to  cover  the  opening,  with  two  lateral  prolongations,  one 
on  each  side,  extending  to  the  teeth,  to  which  they  are  fastened  by 
means  of  ligatures.  This  was  also  found  to  be  objectionable,  as  the 
ligatures  were  productive  of  constant  irritation  to  the  gums ;  moreover, 
they  did  not  hold  the  plate  in  place  with  sufficient  stability,  and  its 
use  was  soon  abandoned.     But  these  objections  were  both  obviated  by 


OBTURATORS   AND   ARTIFICIAL   PALATES. 


963 


an  improvement  made  by  M.  Delabarre,  which  consisted  in  the  em- 
ployment of  clasps,  instead  of  ligatures,  attached  to  lateral  branches  of 
the  plate.  To  prevent  these  from  slipping  too  high  up  on  the  teeth, 
he  attached  to  each  a  kind  of  spur,  which  was  so  bent  as  to  come  down 
over  the  grinding  surface  of  the  tooth  to  which  it  was  applied.  The 
last-named  author  also  made  another  modification,  which  consisted  in 
the  application  of  a  drum  to  the  upper  surface  of  the  plate  (Fig. 
720).  The  object  of  this  was  to  prevent  the  accumulation  of  mucous 
fluids  from  the  nose  in  the  cul  de  sac,  formed  by  simply  closing  the 
opening  below  ;  also  to  prevent  fluids,  in  swallowing,  from  passing  up 
between  the  obturator  and  the  soft  parts,  through  the  opening  into  the 
nose.  The  drum  evidently  ofiers  the  same  impediment  to  nature's 
efforts  in  closing  the  opening  as  the  obturator  before  mentioned;  on 
this  score,  therefore,  it  is  equally  objectionable. 

When  the  opening  in  the  palate  is  small,  and  has  no  connection  with 
the  velum,  it  is  unnecessary  to  raise  the  upper  surface  of  the  plate  by 


Fig.  720. 


Fic.  721. 


attaching  a  drum  or  air  chamber  to  it.  If  it  be  accurately  fitted  to 
the  vault  of  the  palate,  it  will  effectually  prevent  fluids,  in  deglutition, 
from  passing  up  in  the  nasal  cavities,  or  the  escape  of  any  portion 
of  the  voice  through  the  opening ;  also  by  frequently  removing  the 
plate,  the  accumulation  of  the  secretions  in  the  cul-de-sae  will  be  pre- 
vented. A  simple  plate,  like  the  one  represented  in  Fig.. 721  will  be 
all  that  is  required  to  remedy  the  defect ;  and  this,  in  fact,  will  prob- 
ably be  found  the  best  form  in  all  cases,  whether  the  openings  be 
large  or  small. 

Fig.  722  represents  an  obturator  without  teeth  and  without  clasps, 
for  a  perforation  of  the  hard  palate,  being  sustained  in  situ  by  imping- 
ing upon  the  natural  teeth  with  which  it  comes  in  contact.  Accuracy 
of  adaptation  and  delicacy  in  form  are  all  that  is  essential  in  such 
cases,  and  the  restoration  of  the  speech  will  follow  immediately. 

A  clumsy  contrivance  will  interfere  with  articulation  almost  as 
much  as  it  is  improved  by  stopping  the  opening;  therefore,  if  the 


964 


MECHANICS. 


obturator  could  be  confined  entirely  to  the  opening,  like  a  cork  in  a 
bottle,  it  would  be  more  desirable.  As  this  cannot  be,  resort  must  be 
had  to  clasping  the  contiguous  teeth,  if  there  are  any ;  if  there  are 
none,  the  obturator  must  extend  over  the  whole  jaw,  and  receive  its 
support  in  the  same  manner  as  would  a  set  of  artificial  teeth.  In  fact, 
this  is  precisely  what  it  becomes  in  such  a  case — an  upper  set  of  teeth 
bridging  over  and  filling  up  an  opening  in  the  palate,  thus  combining 
an  obturator  with  a  denture.  Fig.  723  represents  a  more  complicated 
obturator,  adapted  to  an  opening  in  the  soft  palate.  The  necessity  for 
a  variation  in  the  plan  will  be  found  in  the  anatomical  fact  of  the 
constant  muscular  action  of  the  soft  palate,  which  would  not  permit, 
without  irritation,  the  presence  of  an  immovable  fixture.  This  is  con- 
trived, therefore,  with  a  joint,  which  will  permit  the  part  attached  to 
the  teeth  to  remain  stationary,  while  the  obturator  proper  is  carried 
up  or  down  as  moved  by  the  muscles.     The  joint,  A,  should  occupy 


Fig.  722. 


Fig.  723. 


the  position  of  the  junction  of  the  hard  and  soft  palates.  The  joint 
and  principal  part  of  the  appliance  is  made  of  gold ;  the  obturator,  of 
vulcanite.  The  projection,  B,  lies  like  a  flange  upon  the  superior 
surface  of  the  palate,  and  sustains  it;  otherwise  the  mobility  of  the 
joint  would  allow  it  to  drop  out  of  the  opening.  This  flange  is  better 
seen  in  the  side  view,  marked  C.  It  is  readily  placed  in  position  by 
entering  the  obturator  first,  and  carrying  the  clasps  to  the  teeth 
subsequently. 

Figs.  722  and  723  will  illustrate  the  essential  principles  involved  in 
all  obturators.  The  ingenuity  of  the  dentist  will  often  be  taxed  in 
their  application,  as  the  cases  requiring  such  appliances  all  vary  in 
form  and  magnitude.  The  steps  to  be  taken  in  the  formation  of  an 
obturator  are  not  unlike  those  used  in  making  a  base  for  artificial 
teeth.  It  is  essential  that  an  accurate  model  be  obtained  of  the  open- 
ing, the  adjacent  palatal  surface,  and  the  teeth,  if  any  remain  in  the 
jaw.  For  this  purpose,  an  impression  taken  in  plaster  is  the  only 
kind  to  be  relied  upon.     Care  must  be  used  that  a  surplus  of  plaster  is 


ARTIFICIAL   PALATES.  965 

not  forced  through  the  opening,  thus  preventing  the  withdrawal  of 
the  impression  by  an  accumulated  and  hardened  mass,  larger  than  the 
opening  through  which  it  passed.  To  avoid  this,  beginners  or  timid 
operators  had  better  take  an  impression  in  the  usual  manner,  with  wax. 
If  this  is  forced  through,  it  can  be  easily  removed  without  injury  to 
the  patient.  From  this  wax  impression  make  a  plaster  model,  and 
upon  this  plaster  model  form  an  impression  cup  of  sheet  gutta-percha, 
using  a  stick,  piece  of  wix-e,  strip  of  metal,  or  any  other  convenient 
thing,  for  a  handle.  This  extemporized  impression  cup  must  not 
impinge  upon  the  borders  of  the  opening,  neither  should  it  enter  to 
any  extent.  With  a  uniform  film  of  soft  plaster,  of  from  one-sixteenth 
to  one-eighth  of  an  inch  in  thickness,  laid  over  this  cup,  a  correct 
impression  can  be  taken  without  any  surplus  to  give  anxiety.  Upon 
a  correct  plaster  model,  taken  from  such  an  impression,  the  obturator 
should  be  moulded  out  of  gutta-percha,  or  any  other  plastic  substance  ; 
the  subsequent  steps  being  in  principle  the  same  as  in  making  any 
other  piece  of  vulcanite.  It  is  desirable  that  it  should  enter  the 
perforation,  and  restore,  as  far  as  possible,  the  lost  portion  of  the 
palate  ;  but  it  must  not  intrude  into,  or  in  any  way  obstruct,  the  nasal 
passage.  The  entire  freedom  of  the  nasal  passage  is  essential  to  the 
purity  of  articulation.  That  portion  of  the  obturator  which  occupies 
the  oral  cavity  should  be  made  as  delicate  as  possible,  consistent  with 
its  strength  and  durability. 

ARTIFICIAL  PALATES. 

Before  proceeding  to  a  description  of  artificial  palates,  a  brief  refer- 
ence to  the  anatomical  relations  and  functions  of  the  velum  palati  will 
be  necessary.  The  palate  exercises  quite  as  important  an  ofiice  in  the 
articulation  of  the  voice  as  does  the  tongue  or  lips.  Being  a  muscular 
and  movable  partition  to  separate  the  nasal  and  oral  cavities,  one  edge 
is  attached  to  the  border  of  the  hard  palate,  while  the  other  vibrates 
between  the  pharynx  and  the  tongue.  The  voice,  therefore,  as  it  issues 
from  the  larynx,  is  directed  by  the  palate  entirely  into  the  mouth,  or 
through  the  nose,  or  permitted  to  pass  both  ways. 

A  vei-y  slight  deviation  in  this  organ  from  its  natural  form  will 
make  the  voice  give  a  different  sound  ;  so  the  presence  of  anything 
that  clogs  the  natural  passages,  either  oral  or  nasal,  modifies  the  vocal 
vibrations.  Place  any  obstruction  in  the  nasal  passages,  paralyze  the 
soft  palate,  or  let  it  be  deficient  in  size,  and  the  power  of  distinct 
articulation  is  wanting.  Evidence  of  this  statement  is  very  frequently 
found,  after  the  surgeon  has  successfully  performed  the  operation  of 
staphylorraphy  in  case  of  congenital  fissure.  In  such  instances  (with 
rare  exceptions)  the  newly-formed  palate  is  so  deficient  in  length,  and 


966 


MECHANICS. 


Fig.  724. 


SO  tense,  as  to  be  deprived  of  its  function.  It  cannot  be  raised  so  as 
to  meet  the  pharynx  and  shut  off  the  nasal  passage,  but  hangs  like  an 
immovable  septum  to  divide  the  column  of  sound. 

Fig.  724  represents  a  defective  palate  belonging  to  the  first  class, 
the  uvula  and  a  portion  of  the  contiguous  soft  palate  being  destroyed 
by  disease.  In  such  a  case  an  obturator  would  be  useless  ;  the  con- 
stant activity  of  the  surrounding  parts  would  not  tolerate  it.  The 
material  used  for  a  substitute  must  be  soft,  flexible  and  elastic ;  and 

the  elastic  vulcanite  is  admirably 
adapted  to  this  purpose. 

By  observing  the  cut  (Fig.  724), 
it  will  be  seen  that  a  portion  of  the 
soft  palate  along  the  median  line 
remains,  and  consequently  there 
will  be  considerable  muscular 
movement  which  must  be  pro- 
vided for,  and  which  may  be  taken 
advantage  of.  It  is  desirable  to 
make  this  movement  available  in 
using  an  artificial  palate,  as  thereby 
more  delicate  sounds  are  produced 
than  otherwise. 

This  case  presented  some  extra- 
ordinary difficulties  in  the  fact 
that  all  the  teeth  of  the  upper  jaw 
had  been  extracted  ,•  and  it  was  necessary,  therefore,  to  adapt  a  plate 
which  should  not  only  sustain  the  teeth  for  mastication,  but  bear  the 
additional  responsibility  of  supporting  the  artificial  palate.  In  the 
choice  of  material  best  adapted  as  a  base  for  the  teeth  in  such 
instances,  it  is  preferable  to  adopt  that  which  will  prove  the  most 
durable.  There  are  too  many  interests  involved  to  risk  the  adoption 
of  anything  but  the  best.  In  the  case  under  description  the  patient 
desired  duplicates,  and  two  sets  of  teeth  were  made,  one  on  gold,  and 
the  other  on  platina,  with  continuous  gum.  The  plates  were  made 
like  other  sets  of  tfeeth,  with  the  exception  of  a  groove  located  on  the 
median  line  at  the  posterior  edge,  to  receive  the  attachment  for  the 
palate  (marked  C  in  Fig.  725). 

Fig.  725  will  indicate  the  set  of  teeth  with  palate  attached.  The 
wings,  marked  A  and  B,  are  made  of  soft  rubber  ;  the  frame  to  support 
them  is  made  of  gold,  with  a  joint  to  provide  for  the  perpendicular 
motion  of  the  natural  palate,  as  in  the  case  of  the  obturator  repre- 
sented in  Fig.  723.  When  the  artificial  palate  is  in  use,  the  joint  and 
frame  immediately  contiguous  lie  close  to  the  roof  of  the  mouth;  the 


ARTIFICIAL   PALATES. 


967 


rubber  wing,  letter  A,  bridges  across  the  opening  on  the  inferior 
surface  or  side  next  the  tongue ;  the  wing,  letter  B,  bridges  across  the 
opening  on  the  superior  or  nasal  surface,  and  is  also  prolonged  back- 


FiG.  725. 


ward  until  it  nearly  touches  the  muscles  of  the  pharynx,  when  they 
are  in  repose. 

Both  these  wings  reach  beyond  the  boundary  of  the  opening  and 
rest  on  the  surface  of  the  soft  palate  for  a  distance  of  from  one-eighth 
to  one-quarter  of  an  inch,  thus  embracing  the  entire  free  edge  of  the 
soft  palate.  This  last  provision  enables  the  natural  palate  to  carry  the 
artificial  palate  up  or  down,  as  articulation  may  require. 

When  the  organs  of  speech  are  in  repose  there  is  an  opening  behind 
the  palate  sufficient  for  respiration  through  the  nares.  When  these 
organs  are  in  action,  a  slight  elevation  of  the  palate,  or  a  contraction 
of  the  pharynx,  will  entirely  close  the  nasal  passage,  and  direct  all  the 
voice  through  the  mouth.  The  palate  thus  becomes  a  valve  to  open 
or  close  the  nares,  and  to  be  tolerated  must  be  made  with  thin, 
delicate  edges  which  will  yield  upon  pressure.  An  instrument  thus 
made  will  restore,  as  far  as  is  possible  by  mechanism,  the  function  of 
the  natural  organ. 

Fig.  726  represents  the  artificial  palate  separated  into  its  constituent 
parts.  The  frame  is  bent  at  the  joint  in 
the  engraving  to  show  a  stop,  marked 
D,  which  prevents  the  appliance  from 
dropping  out  of  position.  Letter  C  shows 
the  tongue,  which  enters  the  groove  in 
the  plate  of  teeth  and  connects  them. 
Letters  A  and  B  are  the  rubber  flaps, 
which  are  secured  to  the  frame  by  the 
hooks,  as  seen  in  the  engraving.  The 
process  for  making  the  rubber  wings 
will  be  found  described  on  page  983. 


968 


MECHANICS. 


Fig.  727  shows  a  more  extensive  palatine  defect  of  the  first  class. 
In  this  case  the  entire  soft  palate  is  gone,  together  with  a  small 
portion  of  the  hard  palate  at  the  median  line.  Although  this 
defect  is  greater  in  extent,  the  means  for  its  remedy  are  more  simple. 
The  muscles  of  the  palate  are  entirely  gone,  and,  consequently,  no 
perpendicular  movement  need  be  provided  for.  The  appliance  in 
this  case  will  resemble  an  elastic  obturator  more  than  the  valve-like 
palate  of  the  preceding  one.  The  principle  here  adopted  is  sub- 
stantially that  recommended  by  Mr.  Sercombe,  of  London,  some  years 
since,  and  consists  of  a  plate  with  a  set  of  teeth  in  the  usual  form, 
and  attached  to  its  posterior  edge  an  apron  of  soft  rubber,  which 


Fig.  727. 


Fig.  728. 


shall  bridge  the  opening  on  its  inferior  surface,  extending  nearly  to 
the  pharynx.  Fig.  728  represents  the  set  of  teeth  with  the  palate  at- 
tached. In  Mr.  Sercombe's  appliance  this  apron  was  made  of  the 
common  sheet  rubber  in  the  market,  prepared  for  other  uses,  and  is 
objectionable  for  two  reasons:  1st.  A  want  of  purity  in  the  materials 
of  which  it  is  compounded  ;  in  many  instances  substances  being  used  in 
its  manufacture  which  would  prove  deleterious  to  the  health  of  the 
patient;  and,  2d,  its  uniformity  of  thickness.  It  is  far  preferable, 
therefore,  to  make  a  mould  from  which  to  form  a  palate  of  pure  and 
harmless  materials ;  one  which  shall  be  of  sufficient  thickness  in  the 
central  part  and  at  its  anterior  edge,  to  give  it  stability,  and  yet 
shall  have  a  thin  and  delicate  boundary  wherever  it  comes  in  contact 


ARTIFICIAL   PALATES.  969 

with  movable  tissue.  Such  a  palate  may  be  made  in  a  mould  by  sub- 
stantially the  same  process  as  hereafter  described.  (See  page  988.) 
It  may  be  secured  to  the  plate  by  a  variety  of  simple  means.  One, 
which  will  give  as  little  trouble  to  the  patient  as  any  other,  is  to  make 
a  series  of  small  holes  along  the  edge  of  the  plate,  and  stitch  it  on 
with  silk ;  or  fine  platina,  gold,  or  silver  wire  may  be  used.  It  is  de- 
sirable in  this  case  to  have  the  plate  and  palate  present  a  uniform 
surface  on  the  lingual  side.  In  fitting  the  plate,  therefore,  it  may  be 
raised  along  the  posterior  edge  from  the  sixteenth  to  the  tenth  of  an 
inch,  according  to  the  thickness  of  the  palate  desired.  The  rubber 
will  thus  be  placed  on  the  palatine  surface  of  the  plate,  and  present 
uniformity  on  the  lingual  surface. 

A  little  thought  will  show  that  in  this  case  the  patient  must  educate 
the  muscles  of  the  pharynx  alone  to  do  the  work  of  shutting  oflP  the 
nares,  which,  in  the  former  case,  was  performed  by  them  in  conjunc- 
tion with  the  muscles  of  the  palate.  Perfection  of  articulation  will, 
therefore,  depend  upon,  the  success  of  the  patient  -in  this  new  use  of 
these  muscles. 

In  cases  of  accidental  lesions  of  the  palate,  such  as  are  under  con- 
sideration, this  education  of  the  muscles  to  a  new  work  will  not  be 
difficult.  The  patient  at  some  former  time  has  had  the  power  of  dis- 
tinct articulation  ;  his  ear  has  recognized  in  his  own  voice  the  contrast 
between  his  present  and  former  condition ;  the  ear  will  therefore  direct 
and  criticise  the  practice  until  the  result  is  attained. 

In  the  case  illustrated  by  Figs.  727,  728,  the  defect  had  existed  for 
twenty-eight  years,  the  patient,  at  the  time  of  the  introduction  of  the 
artificial  palate,  being  nearly  fifty  years  of  age.  The  efi^ect  upon  the 
speech  was  instantaneous.  Articulation  was  immediately  almost  as 
distinct  as  in  youth  ;  and  this  remarkable  distinctness  can  only  be  ac- 
counted for  upon  the  assumption  that  the  pharyngeal  muscles  had 
undergone  a  thorough  training  in  the  vain  effort  to  articulate  without 
any  palate.* 

These  two  cases,  chosen  to  illustrate  the  application  of  artificial 
palates  in  accidental  lesion,  have  required,  as  will  have  been  per- 
ceived, entire  upper  sets  of  artificial  teeth  in  connection  with  the 
palates.  This  selection  was  purposely  made  because  the  difficulties  to 
be  overcome  are  much  greater.  In  cases  where  there  are  natural 
teeth  remaining  in  the  upper  jaw,  the  palate  and  its  connection  with 
a  plate  would  be  substantially  the  same,  and  the  plate  might  easily 
be  secured  to  the  teeth  by  clasps  in  the  same  manner  as  a  partial 
denture. 

*  An  account  of  this  case  appears  in  the  Argus,  of  Bainbridge,  Georgia, 
August  1st,  1868,  written  by  the  patient  himself,  who  is  the  editor  of  that  paper. 


970 


MECHANICS. 


Artificial  Palates  for  Congenital  Fissure. — Congenital  fissure  of  the 
palate  presents  far  greater  difficulties  to  be  overcome  than  cases  of 
accidental  lesion.  The  opening  is  commonly  more  extensive,  the  ap- 
pliance more  complicated,  and  the  result  more  problematical.  Never- 
theless, appliances  have  been  made  in  a  large  number  of  cases  which 
have  enabled  the  wearers  to  articulate  with  entire  distinctness,  so  much 
so  as  not  in  the  least  to  betray  the  defect. 

The  first  efforts  made  in  this  direction  resembled  obturators.  They 
were  simply  plugs  to  close  the  posterior  nares,  and  the  results  were  far 
from  satisfactory.  It  was  not  until  it  was  recognized  that  the  two 
classes  of  cases,  accidental  and  congenital,  were  entirely  distinct,  that 
much  progress  was  made. 

Nearly  every  case  of  accidental  lesion  can  be  treated  by  an  obtu- 


FlG, 


rator  with  considerable  success;  but  very  rarely  will  an  obturator  be  of 
any  benefit  in  congenital  fissure,  even  if  the  congenital  and  accidental 
cases  present  substantially  the  same  form  of  opening.  For  this  reason 
much  embarrassment  has  been  thrown  around  these  appliances  within 
a  few  years  past.  The  character  of  the  different  classes  has  been  con- 
founded, and  an  instrument  admirably  adapted  to  one  class  has  had 
claimed  for  it  an  equal  application  to  the  other  class.  Let  it  be  under- 
stood, therefore,  as  a  rule  to  which  there  will  be  but  few  exceptions, 
that  congenital  fissure  of  the  soft  palate  requires  for  its  successful  remedy 
a  soft,  elastic  and  movable  appliance ;  and  that,  with  the  most  skillfully 
made  instrument,  vocal  articulation  must  be  learned  like  any  other 
accomplishment.  Various  inventions  have  been  made  for  this  purpose 
within  the  last  twenty-five  years,  from  the  most  complicated  one  of  Mr. 


ARTIFICIAL   PALATES. 


971 


Stearns,  described  in  a  former  edition  of  this  work,  to  the  extremely 
simple  one  of  bridging  the  gap  with  a  single  flap  of  rubber.  The 
Stearns  instrument,  .with  all  its  complexity,  embodied  the  only  true 
principle,  viz.,  the  rendering  available  the  muscles  of  the  natural  palate 
to  control  the  movements  of  the  artificial  palate. 

The  essential  requisites  of  an  artificial  palate  are  (1)  to  replace,  as 
far  as  possible,  the  natural  form  of  the  defective  organs  (2)  with  such 
material  as  shall  restore  their  functions.  Muscular  power  certainly 
cannot  be  given  to  a  piece  of  mechanism,  but  the  material  and  form 
may  be  such  that  it  will  yield  to,  and  be  under  the  control  of,  the 
muscles  surrounding  it,  and  thus  measurably  bestow  upon  it  the  func- 
tion of  the  organ  which  it  represents. 

Fig.  729  represents  a  model  of  a  fissured  palate,  complicated  with 
harelip  on  the  left  of  the  median  line.  There  is  a  division  also  of  the 
maxilla  and  the  alveolar  process;  the  sides, being  covered  with  mucous 
membrane,  lie  in  contact  with  each  other,  but  they  are  not  united. 
If  it  is  desired,  a  very  simple  surgical  operation  can  be  performed 

Fig.  730. 


which  will  unite  both  soft  and  hard  tissues  at  this  point  of  division. 
The  left  lateral  incisor  and  left  canine  tooth  are  not  developed.  Fig. 
730  represents  the  artificial  velum  as  viewed  upon  its  superior  surface, 
together  with  the  attachment  of  a  plate  containing  a  clasp  and  two 
artificial  teeth  to  fill  the  vacancy. 

The  lettered  portion  of  this  appliance  is  made  of  elastic  vulcan- 
ized rubber ;  its  attachment  to  the  teeth,  of  hard  vulcanized  rubber, 
to  which  the  velum  is  connected  by  a  stout  gold  pin,  firmly  im- 
bedded at  one  end  in  the  hard  rubber  plate.  The  other  end  has  a 
head,  marked  C,  which  being  considerably  larger  than  the  pin  and 
than  the  corresponding  hole  in  the  velum,  it  is  forced  through — the 
elasticity  of  the  velum  permitting — and  the  two  are  securely  con- 
nected. The  process  B  laps  over  the  superior  surface  of  the  maxilla 
(the  floor  of  the  nares),  and  effectually  prevents  all  inclination  to 
droop.  The  wings.  A,  A,  reach  across  the  pharynx,  at  the  base  of  the 
chamber  of  the  pharynx,  behind  the  remnant  of  the  natural  velum. 


972 


MECHANICS. 


The  wings,  D,  D,  rest  upon  the  opposite  or  anterior  surface  of  the  soft 
palate. 

Fig.  731  represents  a  model  the  same  as  Fig.,729,  with  the  appli- 
ance, Fig.  730,  in  situ ;  the  wing,  D,  D,  in  Fig.  730,  and  the  posterior 
end  of  the  artificial  velum  A  alone  being  visible  in  this  figure. 

The  reader  will  bear  in  mind  that  the  essential  characteristics  of 
this  appliance  are  a  soft,  elastic  substance  filling  the  gap  in  the  soft 
palate,  with  a  flap  behind  as  well  as  before,  which  enables  it  to  follow 
all  movements  of  the  muscles  with  which  it  comes  in  contact,  and  thus 
perform,  to  a  very  considerable  degree,  the  function  of  the  fully 
developed  natural  organ. 

It  is  this  characteristic  alone  which  made  the  Stearns  palate  a 
success,  and  to  produce  which  result  Stearns  invented  the  complicated 


and,  for  most  cases  impracticable,  machinery  as  seen  in  Figs.  737  and 
738.  It  was  to  produce  the  same  effect  by  a  simple  appliance,  that 
the  writer  labored  unremittingly  for  more  than  ten  years ;  the  appli- 
ance of  to-day  being  no  modification  in  any  sense  of  the  Stearns 
instrument,  nor  of  that  of  any  other  author,  but  an  individual  and 
separate  invention,  so  very  simple  that  we  can  conceive  of  no  different 
way  by  which  perfection  of  result  can  be  so  nearly  attained.  A  hun- 
dred instruments  of  like  character  now  being  successfully  worn  attest 
the  writer's  confidence  in  it.  Simplicity  has  gone  but  one  step  further, 
and  that  has  been  to  leave  off  entirely  the  posterior  flap  marked  A,  A 
in  Fig.  730.  This  has  been  done  in  England,  France  and  Germany, 
and  occasionally  in  our  own  country,  and  a  parade  made  of  the  fact, 
as  an  improvement  on  the  inventions  of  the  writer;  but  the  experience 


ARTIFICIAL   PALATES. 


973 


of  the  past  shows  that  in  all  these  cases  the  makers  have  failed  to  com- 
prehend, the  requirements  of  the  case,  and  have,  in  attempting  to 
improve  the  instrument,  dispensed  with  one  of  its  essential  charac- 
teristics. 

A  later  invention,  and  one  which  the  author  believes  to  be  of  almost 
universal  application,  is  represented  in  Fig.  732.  To  appreciate  the 
importance  of  this  invention,  it  must  be  borne  in  mind  that  heretofore 
an  instrument  peculiar  in  form  has  been  required  for  every  separate 
case.  Each  appliance  being  made  in  a  mould  of  special  adaptation, 
has  therefore  entailed  upon  the  operator  a  large  amount  of  labor. 

With  this  later  invention  it  is  believed  that  with  a  few  moulds, 
producing  a  limited  variety  of  palates  adapted  to  the  leading  features 
in  such  cases,  nearly  every  case  of  congenital  cleft  can  be  provided 

Fig.  732. 


for,  upon  the  same  principle  as  other  forms  of  surgical  appliance  are 
made  for  general  use.  It  was  only  after  years  of  experience  and  the 
observation  of  many  cases  that  the  characteristics  which  were  common 
to  all  could  be  determined. 

Those  common  features  are :  (a)  The  fissure  through  the  soft  palate 
is  always  in  the  median  line  ;  (b)  the  variations,  if  any,  from  the  median 
line  are  anterior  to  the  soft  palate,  in  the  palatine  and  maxillary 
bones  ;  (c)  thickness  of  the  border  of  the  fissure  in  the  remnant  of 
the  soft  palate  is  generally  uniform  ;  {d)  the  sides  correspond  very 
nearly  with  each  other  in  length,  breadth,  thickness,  and  contour  ; 
(e)  the  chief  variation  in  nearly  all  clefts  of  the  soft  palate  is  in  their 
size  or  breadth,  and  this  is  true  without  any  reference  as  to  whether 
the  fissure  extends  forward  into  the  hard  palate  or  not.    Figs.  729  and 


974  MECHANICS. 

732  represent  two  cases  of  remarkable  general  likeness,  although  they 
differ  twenty  years  in  age,  and  more  than  five  years  in  the  period  of 
time  at  which  they  were  treated. 

The  palate  placed  in  situ  in  Fig.  732  shows  an  instrument  which, 
with  variations  in  size,  is  of  almost  universal  application.  It  is  nearly 
identical  with  the  palate,  Figs.  730  and  731,  were  that  one  cut  across 
the  middle.  Like  the  other,  it  is  made  of  soft  rubber,  and,  moreover, 
it  will  need  an  additional  fixture  to  fill  the  gap  in  the  hard  palate  and 
also  keep  the  artificial  velum  from  being  swallowed.  In  Fig.  730  there 
is  a  projection  marked  B,  which  is  made  of  soft  rubber,  and  is  a  part 
of  the  velum.  This  projection,  as  has  already  been  noticed,  is  intended 
to  assist  in  supporting  the  velum  in  position.  This  is  not  always 
necessary  or  desirable ;  there  are  cases  where  the  velum  is  quite  as 
well  sustained  without  this  projection,  and  where,  if  it  were  applied, 
it  would  certainly  injure  the  tone  of  the  voice  by  clogging  the  nasal 
passage.  In  the  case  Fig.  732,  if  support  were  desired  by  lapping  on 
the  floor  of  the  nares,  toward  the  apex  of  the  fissure,  it  would  form  a 
portion  of  the  hard  palate  or  obturator,  instead  of  being  part  of  the 
velum  or  soft  palate,  as  heretofore. 

OBTURATORS  AND  PALATES  COMBINED. 

We  shall  proceed  now  to  consider  another  class  of  cases,  the  proper 
treatment  of  which  has  been  followed  by  the  most  encouraging  results. 

For  fifty  years  the  operation  of  staphylorraphy  has  been  a  favorite 
one  with  surgeons,  yet  the  number  of  cases  in  which  there  has  been 
only  a  partial  union  are  largely  in  the  majority.  In  many  instances 
all  that  has  been  accomplished  is  simply  the  tying  together  of  a  small 
portion  of  the  soft  palate,  across  the  back  part  of  the  fissure,  leaving 
an  opening,  of  greater  or  less  size,  through  the  hard  palate,  anterior 
to  the  newly-formed  septum.  This  opening  has  generally  been  plugged 
with  an  obturator ;  but  vocal  articulation  has  been  little,  if  at  all, 
improved.  To  meet  this  emergency  a  new  form  of  artificial  velum  was 
invented.  Fig.  733  will  illustrate  such  a  case,  with  the  obturator  and 
artificial  palate  in  situ. 

The  patient  was  a  man  fifty  years  of  age.  The  operation  of  staphy- 
lorraphy had  been  performed  twenty  years  previously  ;  an  obturator  of 
silver,  and  afterward  one  of  vulcanite,  has  been  worn  constantly  ever 
since.  Nevertheless  the  articulation  was  not  benefited,  the  reason 
being  the  same  as  in  every  other  case  of  staphylorraphic  operation  ; 
the  new  fleshy  palate,  marked  A,  not  being  long  enough  to  close  by 
any  muscular  efibrt  the  passage  to  the  nares.  There  was,  however, 
some  remaining  muscular  action,  to  utilize  which  power  was  the 
desired  object  to  be  attained.     Letter  B  shows  the  obturator,  the  letter 


OBTUEATORS   AND    PALATES   COMBINED. 


975 


C  the  velum.  In  this  instance  the  obturator  is  made  of  soft  rubber, 
the  same  as  the  velum,  and  when  in  use  the  velum  is  but  an  extension 
of  the  natural  palate,  as  seen  in  Fig.  733. 

Fig.  733. 


Fig.  734  shows  the  appliance  when  not  in  use.  The  plate  D  secures 
the  obturator  to  the  teeth,  as  in  other  cases  of  artificial  palates.  In 
order  to  introduce  the  piece,  the  broad  flap,  C,  should  be  first  passed 
through  the  opening  in  the  roof,  and  pushed  back  ;  the  whole  fixture 

Fig.  734. 


•will  readily  fall  into  correct  position.     In  the  case  of  this  patient,  the 
improvement  in  vocal  articulation  was  immediate  and  very  decided. 

Fig.  735  illustrates  another  case  of  a  similar  character,  but  with 
incidental  circumstances  much  more  interesting.  The  patient  was  a 
lady,  sixty-two  years  of  age,  for  whom  staphylorraphy  was  performed 
in  1845,  by  a  distinguished  surgeon,  and  the  result  was  a  remarkable 


976 


MECHANICS. 


success,  so  far  as  the  union  of  the  parts  was  concerned.  The  union  was 
perfect  throughout  the  entire  length  of  the  fissure,  including  the 
uvula ;  but  although  the  patient  had  applied  herself  diligently  to  the 
improvement  of  her  speech,  she  was  unsatisfied  with  her  progress. 
The  fault  being  the  same  as  in  all  other  cases — too  short  a  palate — the 
remedy  must  be  the  same.  But  here  arose  another  difficulty.  There 
was  no  opening  through  the  roof  of  the  mouth,  as  in  case  of  Fig.  732, 
and  there  was  no  method  of  securing  the  desired  palate  extension  to 
the  inferior  surface  of  the  natural  palate.  To  convey  to  the  artificial 
velum  the  action  of  the  levatores  palati  was  essential  to  success.  After 
consultation  with  a  skillful  and  distinguished  surgeon  of  this  city  (Dr. 

Fig.  735. 


Geo.  A.  Peters,  New  York),  it  was  decided  to  undo,  in  a  measure,  the 
operation  of  twenty -five  years  before ;  and  an  opening  was  made  through 
the  soft  palate  on  the  median  line  immediately  behind  the  hard  palate, 
as  shown  in  Fig.  735.  The  opening  was  a  simple  straight  incision, 
which  was  subsequently  enlarged  by  wearing  a  tent  for  a  short  time. 
There  was  no  pain ;  but  little  bleeding  ;  and  in  a  few  days  it  was 
entirely  healed.  What  complicated  the  case  still  further  was  the  loss 
of  all  the  teeth  in  the  upper  jaw,  and  an  entire  upper  denture  had 
been  worn  for  years.  The  artificial  palate  was  attached  to  such  a 
dentui'e,  and  instead  of  proving  detrimental  to  the  denture,  it  was  an 
advantage ;  serving,  when  in  place,  to  keep  the  back  edge  of  the  plate 
from  the  possibility  of  dropping.    The  marked  improvement  in  articu- 


OBTURATORS   AND    PALATES   COMBINED.  977 

lation  and  the  gratification  of  the  patient  were  a  sufficient  justification 
for  the  partial  undoing  of  such  an  admirable  surgical  operation. 

The  later  experience  of  the  writer  favors  the  idea  of  a  partial 
staphylorraphic  operation,  with  a  view  of  making  a  narrow  bridge 
across  the  posterior  part  of  the  fissure.  Even  the  tying  of  the  bifur- 
cated uvula  together  would  be  of  far  more  service  to  the  patient  than 
a  union  throughout  the  length  of  the  cleft.  Such  a  slight  bridge  of 
the  gap  is  more  easily  and  certainly  obtained  than  when  greater  at- 
tempts are  made ;  as  the  surgical  operation  can  be  supplemented  by 
an  artificial  velum  of  a  very  simple  character,  the  patient  thus  derives 
the  highest  benefit  which  surgical  skill  can  at  this  day  give. 

Method  of  Making  an  Artificial  Palate. — The  success  of  these  appli- 
ances depends  very  much  upon  the  perfect  accuracy  of  the  model,  since 
it  is  upon  this  that  the  parts  are  moulded.  It  is  essential  that  the 
entire  border  of  the  fissure,  from  the  apex  to  the  uvula  should  be  per- 
fectly represented  in  the  model,  as  these  parts  are  when  in  repose.  It 
is  also  necessary  that  the  model  show  definitely  the  form  of  the  cavity 
above,  and  on  either  side,  of  the  opening  through  the  hard  palate ; 
since  that  part  of  the  cavity  is  hidden  from  the  eye.  It  is  desirable, 
although  it  is  not  essential,  that  the  posterior  surface  of  the  remnant 
of  the  soft  palate  be  shown;  but  it  is  especially  important  that  the 
anterior  or  under  surface  be  represented  with  relaxed  muscles,  and  in 
perfect  repose.  The  impression  for  such  a  model  must  be  taken  in 
plaster ;  it  is  the  only  material  now  in  use  adapted  to  the  purpose. 
An  ordinary  Britannia  impression  cup  may  be  used,  selecting  one  cor- 
responding in  size  and  form  to  the  general  contour  of  the  jaw.  This 
cup  will  be  found  too  short  at  the  posterior  edge  to  receive  the  soft 
palate,  but  it  may  be  extended  by  the  addition  of  a  piece  of  sheet 
gutta-percha,  which  must  be  moulded  into  such  form  as  not  to  impinge 
upon  the  soft  palate,  but  which  will  reach  under  and  beyond  the  uvula, 
and  thus  protect  the  throat  from  any  droppings  of  plaster.  Before 
using  the  plaster,  the  posterior  edge  of  the  gutta-percha  extension  may 
be  softened  by  heat  and  introduced  into  the  mouth.  Contact  with  the 
soft  palate  will  cause  it  to  yield,  so  that  there  is  no  danger  of  its 
forcing  away  the  soft  tissues  when  the  plaster  is  used.  The  first  effort 
will  be  to  get  only  the  lingual  surface,  taking  precaution  not  to  use 
too  much  plaster.  After  trial,  if  the  impression  show  definitely  the 
entire  border  of  the  fissure,  and  the  soft  palate  has  not  been  pushed  up 
by  the  spasmodic  action  of  the  levator  muscles,  it  is  all  that  is  thus 
far  desired.  If,  however,  the  soft  parts  have  been  disturbed  (which, 
on  close  comparison,  a  little  experience  will  decide),  it  is  better  to 
take  a  model  from  the  impression  ;  and  upon  this  model  extemporize 
an  impression  cup,  as  described  on  page  965.  This  temporary  cup  will 
62 


978  MECHANICS. 

have  the  advantage  of  the  former,  inasmuch  as  it  requires  but  a  thin 
film  of  plaster  to  accomplish  the  result,  thus  lessening  the  danger  of 
disturbing  the  soft  tissues.  After  the  removal,  if  it  is  seen  that  any 
surplus  has  projected  through  the  fissure  and  spread  out  over  the  floor 
of  the  nares,  it  should  be  trimmed  off. 

In  most  cases  such  an  impression  will  be  all  that  is  required.  Such 
an  impression  can  be  taken,  with  a  little  experience,  quite  as  readily 
as  a  correct  impression  for  a  set  of  teeth.  The  all-iraportaut  point  is 
to  have  the  border  of  the  fissure  closely  defined,  with  the  soft  parts 
hanging  in  their  relaxed  condition.  It  is  not  essential  to  one  of  ex- 
perience that  the  pharynx  behind  the  uvula  should  be  taken  in  the 
impression.  When  the  model  is  obtained  from  the  impression,  a  repre- 
sentation of  the  pharynx  can  be  made,  with  sufficient  accuracy  for 
practical  purposes,  by  carving.  It  is  only  when  the  floor  of  the  nares 
is  used  for  the  support  of  the  palate  that  it  becomes  necessary  to 
obtain  a  more  complicated  impression,  one  which  shall  represent  not 
only  a  portion  of  the  buccal  cavity,  but  all  the  superjacent  nasal 
cavity.  When  this  is  required,  the  next  step  will  be  to  obtain,  in  con- 
junction with  this  impression  of  the  under  surface  (which  we  call  the 
palatal  impression),  an  impression  of  the  upper  or  nasal  surface  of  the 
hard  palate.  This  can  be  done  by  filling  the  cavity  above  the  roof  of 
the  mouth  with  soft  plaster  down  to  the  border  of  the  fissure,  and, 
while  yet  very  soft,  immediately  carrying  the  palatal  impression 
against  it,  and  retaining  it  in  that  position  until  the  plaster  is  hard, 
which  can  be  easily  ascertained  by  the  remains  in  the  vessel  from 
which  it  was  taken.  Taking  the  precaution  to  paint  the  surface  of  the 
palatal  impression  with  a  solution  of  soap,  to  prevent  the  two  masses 
from  adhering  when  brought  in  contact,  there  will  be  no  difficulty  in 
removing  it  from  the  mouth,  leaving  the  mass  which  forms  the  nasal 
portion  in  situ.  With  a  suitable  pair  of  tweezers  this  mass  is  easily 
carried   backward  and    withdrawn  from    the   mouth ;   the   irregular 

surface  of  contact  indicates  its  rela- 
tion to  its  fellow  when  brought 
together. 

Fig.  736  will  show  such  an  im- 
pression. The  portion  marked  A, 
B,  C  will  readily  be  distinguished 
as  that  which  entered  the  nasal 
cavity.  The  line  of  separation 
from  the  palatal  impression  is 
plainly  indicated  in  the  engraving. 
The  groove  marked  D  shows  clearly 
the  impression  made  by  the  delicate  uvula  in  the  soft  plaster.     The 


OBTURATORS    AND   PALATES  COMBINED.  979 

nasal  portion  is  relatively  large,  showing  an  unusually  large  nasal 
cavity.  The  vomer  lies  between  the  projections  marked  A,  A,  these 
projections  entering  the  nasal  passages.  The  surfaces  marlied  B,  B 
came  in  contact  with  the  middle  turbinated  bones;  the  surface  marked 
C,  in  contact  with  the  inferior  turbinated  bone.  In  many  instances 
these  turbinated  bones  are  so  large  as  nearly  to  fill  the  nasal  passages. 
The  method  of  obtaining  a  model  of  the  mouth  from  this  impression 
does  not  require  any  particular  description.  The  process  is  similar  to 
the  making  of  a  cast  into  any  other  mouth  impression.  The  model 
represented  in  Fig.  735  shows  a  convenient  form  for  such  a  case. 

When  the  nasal  portion  of  the  impression  does  not  indicate  the 
superior  surface  of  the  soft  palate,  the  part  may  be  represented  in  the 
model  by  carving.  It  is  not  essential  to  the  success  of  the  artificial 
palate,  that  the  posterior  surface  of  the  soft  palate  should  be  repre- 
sented with  the  same  accuracy  that  is  required  on  the  inferior  surface 
or  on  both  surfaces  of  the  hard  palate.  By  the  aid  of  a  small  mirror 
and  a  blunt  probe,  the  thickness  of  the  velum  and  the  depth  behind 
the  fissure  can  be  ascertained  ;  approximate  accuracy  is  sufficient,  since 
the  portion  of  the  artificial  palate  coming  in  contact  with  it  is  so 
elastic  that  it  easily  adapts  itself  to  a  slight  inequality,  rendering  abso- 
lute accuracy  less  important. 

The  next  step  will  be  the  formation  of  a  model,  or  pattern,  of  the 
palate.  Sheet  gutta-percha  is  preferable  for  this  purpose,  although 
wax,  or  some  other  plastic  substance,  might  answer.  The  form  which 
should  be  given  is  better  indicated  by  the  drawing.  Figs.  730  and  741, 
than  it  could  be  by  written  description.  The  Stearns  instrument,  of 
which  a  cut  is  here  given  (Figs.  737  and  738),  was  made  to  embrace 
the  edges  of  the  fissure,  and  was  slit  up  through  the  middle,  so  that 
when  the  edges  of  the  fissure  approached  each  other,  as  they  always 
do  in  swallowing,  the  two  halves  of  the  instrument  would  slide  by  each 
other ;  a  third  flap  or  tongue  was  made,  and  supported  by  a  gold 
spring,  to  cover  and  keep  closed  this  central  slit. 

This  complicated  provision  for  the  contraction  of  the  fissure  is 
entirely  superseded  in  Figs.  730  and  741,  by  making  the  instrument 
somewhat  in  the  form  of  two  leaves,  one  to  lie  on  the  inferior  and  the 
other  upon  the  superior  surface  of  the  palate,  and  joined  together 
along  the  median  line.  When  the  fissure  contracts,  the  halves  of  the 
divided  uvula  slide  toward  each  other  between  these  two  leaves.  The 
posterior  portion,  marked  A  in  Fig.  730,  is  made  very  thin  and  deli- 
cate on  all  its  edges,  as  it  occupies  the  chamber  of  the  pharynx,  and  is 
subject  to  constant  muscular  movement.  The  sides  are  rolled  slightly 
upward,  while  the  posterior  end  is  curved  downward.  The  inferior 
portion,  marked  D,  D,  should  reach  only  to  the  base  of  the  uvula,  and 


980 


MECHANICS. 


bridge  directly  across  the  chasm  at  this  point  (Fig.  731) ;  and  no  effort 
to  imitate  the  uvula  should  be  made.  The  extreme  posterior  end 
should  not  reach  the  posterior  wall  of  the  pharynx  by  a  quarter  of  an 
inch  when  all  the  muscles  are  relaxed  (although  subsequent  use  must 
determine  whether  to  increase  or  diminish  this  space),  thus  leaving 
abundant  room  for  respiration  and  for  the  passage  of  nasal  sounds. 
In  cases  where  it  is  desirable  to  make  the  instrument,  as  far  as  possible, 
independent  of  the  teeth  for  its  support,  the  anterior  part  which  occu- 
pies the  apex  of  the  fissure  in  the  hard  palate  may  lap  over  upon  the 
floor  of  one  or  both  nares.  Such  a  projection  is  seen  in  Fig.  730, 
marked  B,  and  a  like  process  is  seen  in  Fig.  741,  but  not  lettered. 
Were  it  not  for  this  process  in   the  first  case,  the  palate  would  drop 


Fig.  737. 


Fig.  738. 


from  the  fissure  into  the  mouth,  the  single  clasp  at  the  extreme  an- 
terior edge  not  being  sufficient  to  keep  the  whole  appliance  in  place 
throughout  its  entire  length.  Caution  must  be  exercised  that  this 
projection  entering  the  nares  be  not  too  large,  or  it  will  obstruct  the 
passage,  and  give  a  disagreeable  nasal  tone  to  the  voice. 

All  the  peculiarities  described  must  be  provided  for  in  the  gutta- 
percha model,  which,  after  having  been  carefully  formed  upon  the 
cast,  may  be  tried  in  the  mouth,  to  ascertain  its  length  or  necessary 
variations.  When  its  ultimate  form  has  been  determined,  provision 
must  be  made  to  duplicate  it  in  soft  rubber.  A  familiar  illustration 
of  the  process  here  to  be  adopted  is  found  in  the  parallel  process  em- 


OBTURATORS   AND    PALATES   COMBINED. 


981 


ployed  when  a  set  of  teeth  is  made  on  the  vulcanite  base.  A  model 
form  is  made  of  wax  and  gutta-percha,  bearing  the  teeth ;  and  in  all 
its  prominent  characteristics  has  the  shape  desired  in  the  completed 
denture,  the  rubber  duplicate  being  vulcanized  in  a  plaster  mould.  In 
like  manner  the  rubber  duplicate  of  the  palate,  as  before  described, 
may  be  made  in  a  plaster  mould. 

If  plaster  is  used  for  the  moulds,  it  must  be  worked  so  that  the  sur- 
face shall  be  free  from  air  bubbles,  or  the  rubber  palate  will  be  covered 
with  excrescences  that  cannot  readily  be  removed.  By  covering  the 
surface  of  the  mould  with  collodion  or  liquid  silex,  it  will  be  much 
improved.  But,  ordinarily,  plaster  moulds  will  be  found  too  trouble- 
some for  general  use.     They  may  be  put  to  a  most  excellent  use,  how- 

FiG.   739. 


ever,  by  using  one  to  make  a  duplicate  of  the  gutta-percha  in  hard 
rubber.  This  is  not  necessary  with  those  who  have  had  much  experi- 
ence, but  with  beginners  it  will  be  difficult  to  work  up  the  gutta-percha 
as  nicely  as  may  be  desired ;  a  duplicate  in  vulcanite  will  enable  the 
operator  to  make  a  more  artistic  model  of  the  palate,  and  one  which 
can  be  handled  with  greater  freedom. 

As,  in  the  course  of  a  lifetime,  a  considerable  number  of  elastic 
palates  will  be  required,  the  mould  which  produces  them  should  be 
made  of  some  durable  material.  The  type  metal  of  commerce  is  ad- 
mirably adapted  to  this  use.  A  very  complete  mould  is  one  made 
of  four  pieces  which  will  produce  a  palate  in  one  continuous  piece. 
Such  a  mould  requires  very  nice  mechanical  skill  in  fitting  all  the 
parts  accurately,  and  unless  the  operator  has  had  experience  in  such  a 
direction  it  is  better  to  simplify  the  matter.  Fig.  739  shows  a  mould 
in  four  pieces.     The  blocks  C,  C  are  accurately  adapted  to  the  body 


982 


MECHANICS. 


of  the  mould,  marked  A,  and  are  prevented  from  coming  into  inaccu- 
rate contact  with  each  other  by  the  flanges  D,  D,  which  overlap  and 
rest  upon  the  sides  of  the  main  piece.  B  shows  the  top  of  the  mould, 
and  the  groove  E  provides  for  the  surplus  rubber  in  packing.  Such  a 
mould  makes  as  perfect  an  appliance  as  can  be  produced.  The  palate 
is  one  homogeneous  and  inseparable  piece.  The  cut  will  sufficiently 
indicate  the  form  of  the  several  parts.  Each  of  these  pieces  is  first 
made  in  plaster,  having  exactly  the  form  desired  in  the  type  metal. 

They  are  then  moulded  in  sand, 
and  the  type  metal  cast  as  in 
making  an  ordinary  die  for 
swaging.  When  in  use,  a  clamp 
similar  to  Pig.  740  is  placed 
around  the  mould,  to  keep  the 
several  parts  firm  in  their,  posi- 
tion. 

Fig.  741  shows  the  palate  com- 
plete, with  its  attachment  to  the 
teeth.  The  palate  is  secured  to 
the  plate  by  a  pin  of  gold  passing 
through  a  hole  of  the  same  size 
in  the  palate ;  the  head  on  the  pin  being  larger  than  the  hole  through 
which  it  is  forced. 

By  making  the  palate  in  two  pieces,  to  be  joined  after  vulcanizing, 
as  shown  in  Fig.  742,  the  mould  may  be  made  in  only  two  pieces,  and 


Fig.  741. 


Fig.  742. 


with  very  little  trouble.  When  in  use,  the  two  pieces,  as  here  repre- 
sented, are  bound  together  at  the  forward  part  by  the  gold  pin  before 
referred  to ;  and  a  few  stitches  of  silk  secure  it  at  the  posterior  part. 

The  instrument  then  becomes  identical  with  that  shown  in  Fig.  741. 

Fig.  743  shows  the  mould  or  flask  in  which  it  is  vulcanized.  These 
flasks  were  made  expressly  for  this  purpose ;  but  they  are  not  so 
unlike  the  flasks  in  common  use   in   dentists'   laboratories  that  the 


OBTURATORS   AND   PALATES    COMBINED. 


983 


latter  will  not  answer.  The  common  flask  is  simply  unnecessarily- 
thick  or  deep. 

The  mould  is  readily  produced  in  the  following  manner  :  Imbed  the 
two  pieces  of  the  palate  in  plaster  in  one-half  of  the  flask  ;  when  the 
plaster  is  set  and  trimmed  into  form,  duplicate  it  in  type-metal  by 
removing  the  palate,  varnishing  the  surface,  moulding  in  sand,  and 
casting.  In  making  the  sand  mould,  take  a  ring  of  sheet  iron  of  the 
same  diameter  as  the  flask  and  three  or  four  inches  high  ;  slip  it  over 
the  flask,  and  pack  full  of  sand.  Separate  them,  remove  the  plaster, 
return  the  flask  to  the  sand  mould,  and  fill  with  the  melted  metal, 
through  a  hole  made  in  the  side  or  bottom  of  the  flask.  Having  thus 
made  one-half,  substantially  the  same  process  will  produce  the  coun- 
terpart. 

Fig.  744  shows  the  mould  which  produces  the  palate  illustrated  by 

Fig.  743. 


Fig.  732.  It  is  the  most  simple,  and  at  the  same  time  the  most  com- 
plete, of  any  mould  yet  invented.  The  mould  is  made  in  three  pieces, 
and  is  enclosed  in  a  flask  exactly  the  same  as  Fig.  743,  but  with  this 
improvement :  the  latter  mould  yields  a  piece  formed  of  two  separate 
parts  of  rubber,  which  must  be  afterward  joined  by  stitching  or  other- 
wise :  while  the  former  (Fig.  744)  produces  an  appliance  in  one  piece, 
and  as  perfectly  finished  as  by  the  more  complicated  mould  of  four 
pieces,  shown  in  Fig.  739.  Letter  A  represents  the  base  of  the  mould  ; 
B,  the  middle  section,  which  is  placed  on  the  top  of  A ;  and  the  third 
section,  or  top,  C,  completes  it. 

The  mechanical  processes  by  which  this  mould  is  made  are  substan- 
tially the  same  as  given  for  making  those  before  described.  The 
packing  of  the  mould  with  rubber  should  be  done  in  the  same  manner 
as  when  hard  rubber  is  used  for  a  dental  base,  with  which  process  it  is 


984 


MECHANICS. 


assumed  that  the  reader  is  familiar.  By  washing  the  surface  of  the 
mould  with  a  thick  solution  of  soap  previous  to  packing,  the  palate 
will  be  more  easily  removed  after  vulcanizing.  The  rubber  used  for 
this  purpose  must  be  a  more  elastic  compound  than  that  for  a  dental 
base-plate.     The  composition  used  for  the  elastic  fabrics  of  commerce 

Fig.  744. 


will  answer,  if  made  of  selected  materials.  There  is  also  on  sale  at  the 
dental  depots  a  soft,  elastic  compound  admirably  adapted  to  the  pur- 
pose, with  accompanying  instructions  for  vulcanizing ;  the  best  results 
being  obtained  by  heating  up  to  230^,  and  gradually  increasing,  during 
four  or  five  hours,  to  270°. 


THE   END. 


INDEX. 


Single  references  will  be  found  under  leading  word  of  title  :  many  subjects  are 
referred  to  under  each  word  of  title,  and  sometimes  under  its  synonym.  Princi- 
pal subjects  are  alphabetically  arranged  ;  but  details  and  sub-divisions  are  usually 
given  in  the  order  of  description  in  the  text,  so  as  to  present  a  full  synopsis  of 
the  subjects  indexed. 


A  BNORMAL  development  and  ar- 

J\.     rangement  of  teeth,  350. 

Abrasion  of  teeth,  chemical,  328 ;  me- 
chanical, 330. 

Abscess,  alveolar,  297 ;'  causes  and 
medical  treatment,  300 ;  surgical 
treatment,  302. 

Absorption,  of  roots  of  deciduous  teeth, 
169;  of  alveolar  walls  around  teeth, 
310;  time  required  after  extraction 
of  teeth,  646. 

Acids,  effects  on  teeth,  Westcott's  and 
Miller's  experiments,  343;  use  in 
refining  gold,  689;  for  pickling 
gold  plate,  739 ;  after  soldering, 
757. 

Actual  cautery  for  destroying  nerve, 
284. 

Adhesion,  of  gum  to  cheek,  222  ;  of  con- 
tact, 799  ;  of  vacuum  cavity,  802  ; 
of  part'al  pieces,  806. 

Adjustment  of  porcelain  teeth,  to  gold 
plate,  759 ;  to  aluminum  plate, 
831;  to  vulcanite  plate,  845. 

.Esthetics  in  selection  and  arrangement 
of  teeth,  635,  765  ;  rules  and  illus- 
trations, 634. 

Alkalies,  action  on  teeth,  348 ;  for 
cleansing  gold  plate,  775  ;  in  com- 
position of,  dental  porcelain,  634; 
continuous  gum,  812. 

Alloys,  for  gold  plate,  698 ;  formulas, 
697  ;  for  dies,  730;  properties  and 
formulas,  697  ;  of  tin,  for  plates, 
820 ;  stannic,  821. 

Alloying  gold,  694. 

Aluminum,  history  and  properties,  829  ; 
refining,  830 ;  swaged  plates  and 
solder,  831 ;  durability  in  mouth, 
830. 
Bean's  alumino-plastic  process,  831 ; 
swaged  aluminum  plates,  831. 

Alveolar  abscess,  297  ;  periostitis,  293. 


Alveolar  processes,  anatomy,  64 ;  ne- 
crosis and  exfoliation,  306 ;  ab- 
sorption, around  teeth,  310;  after 
extraction,  646 ;  hypertrophy  of 
walls,  313.    _ 

Amalgam,  for  filling  teeth  ;  instruments 
for  using,  433. 

Anesthesia,  general,  574 ;  ether  and 
chloroform,  575  ;  hydrate  of  chlo- 
ral, bichloride  of  methylene,  580  ; 
nitrous  oxide  and  apparatus,  575  ; 
bromide  of  ethyl,  580. 

Antesthesia,  local  ;  congelation  ;  hypo- 
dermic injection,  581  ;  electro-mag- 
netism, 583  ;  spray  apparatus,  585  ; 
hydrochlorate  of  cocaine,  586  ;  ob- 
tunders,  586. 

Analysis  of  cementum,  148  :  of  dentine, 
141  ;  of  enamel,  138. 

Anatomical  relations  of  the  mouth, 
104. 

Anatomy  and  physiology  of  the  mouth 
and  face,  54. 

Annealing,  gold  plate,  738. 

Antagonism  of,  artificial  teeth,  765 ; 
natural  teeth,  113. 

Anthracite  coal,  for  melting  gold,  691  ; 
for  porcelain  furnace,  940. 

Antimony,  effect  on  tin,  733  ;  as  alloy 
for  metallic  dies,  730. 

Antrum  Highmorianum,  62  ;  diseases 
of  and  treatment,  697 ;  Dr.  Ab- 
bot's treatment,  613. 

Aqua  regia  process  for  refining  gold, 
689. 

Arkansas,  Hindostan  and  ScotCjh  stones, 
417. 

Arsenious  acid,  action  on  nerve  pulp, 
284. 

Arteries  of  mouth  and  face,  82;  inter- 
nal carotid,  82 ;  external  carotid 
and  branches,  83. 

Articulation,  of  natural  teeth  (gompho- 


985 


986 


INDEX. 


sis).  112;  of  artificial  teeth,  740; 
importance  of  accuracy  in,  747. 

Articulations,  81. 

Articulators,  metallic,  745  ;  plaster,  742. 

Artificial,  palates  or  vela,  965  ;  teeth, 
necessity  and  utility,  627  ;  prepara- 
tion for  inserting,  643  ;  methods  of 
inserting,  636 ;  different  kinds  of, 
631. 

Asbestos,  over  exposed  pulp,  494  ;  use 
in  soldering,  756  ;  continuous-gum, 
810;  porcelain,  942. 

Atmospheric  pressure  ;  history  of  appli- 
cation to  plates,  640,  796  ;  illustra- 
tion of  principle,  797  ;  adhesion  of 
contact.  799  ;  vacuum  cavity,  802. 

Atrophy  of  teeth,  314. 

BABBIT  metal  for  dies,  734. 
Backing  porcelain  teeth ;  prepa- 
ration for,  768  ;  different  forms  and 
processes  for  gold  plate,  773  ;  pivot 
teeth,  647 ;  teeth  for  vulcanite 
plates,  845. 

Bichloride  of  methylene  for  anaesthesia, 
580. 

Bing's  method  of  capping  teeth,  526. 

Biscuiting  porcelain  teeth,  918. 

Bismuth,  use  as  alloy  for  metallic  dies, 
733. 

Bleaching  necrosed  teeth,  322. 

Block  teeth,  porcelain,  759 ;  manufac- 
ture of,  918  ;  special  block  carv- 
ing, 936. 

Blood  vessels  of  mouth  and  face,  82. 

Blowpipe,  mouth,  method  of  using, 
750  ;  alcoholic  or  self-acting,  Parm- 
ly's,  752  ;  mechanical,  753  ;  Fletch- 
er's, 753;  Macomber's  gas,  754. 

Body,  porcelain,  formulas  of  composi- 
tion, 812. 

Bone,  composition  and  development, 
55  ;  maxillary,  superior,  61 ;  infe- 
rior, 65 ;  palate,  G8. 

Bones,  of  head  and  face,  development 
of,  57. 

Bonwili's  engine  mallet,  487. 

Borax,  use  in  melting  gold,  691  ;  in 
soldering,  758  ;  in  composition  of 
continuous  gum,  811 ;  porcelain, 
918. 

Bridge  work,  678. 

Britannia  impression  cups,  707. 

Broaches  for  nerve  filling,  539. 

Bromide  of  ethyl,  580. 

Brush  wheels  for  polishing,  777. 

Building  up  whole  or  part  of  crown  of 
tooth,  516. 

Burnishers,  for  fillings,  493 ;  for  plate 
work,  777. 

Burr  drills,  for  excavating  teeth,  448. 

Burrs  for  finishing  fillings,  492. 


CALCINED  plaster,  711;  silex  and 
feldspar,  810. 
Calculus,    salivary,    240 :  black.   241  ; 
dark    brown.    242  ;  '  white,     243  ; 
dark  green  deposit,  243  ;  excessive 
deposit,    244  ;    chemical   composi- 
tion,  245 ;  origin,  246  ;  effects  on 
teeth,  gums,  and  alveoli,  248;  in- 
struments and  manner  of  removal, 
249. 
Calipers,  825. 
Canaliculi  of  bone,  form  and  function, 

56 ;  cementum,  129. 
Cancrum  oris,  189. 
Carat  valuation  of  gold,  formulas  and 

tables.  696. 
Carbolized  potash,  586. 
Caries   of  the  teeth,    334  ;  liability  to, 
336  ;  causes,  341  ;  prevention,  348  ; 
surgical    treatment,    495 ;    of   the 
maxillary  bones,  619. 
Carriers  for  files,413, 414,492;  tape,492. 
Carving    block   teeth,    936;    Calvert's 

method,  941. 
Cassius,  purple  of,  917. 
Cavities  in  teeth  (see  Filling),  428  ;  va- 
cuum, 802. 
Cells,  structure  and  development  of. 
41  ;  views  of  Schleiden  and 
Schwann,  44 ;  Good.sir,  Huxley, 
45  ;  Henle,  KoUicker,  Barry,  46  ; 
Bennett,  Todd,  and  Bowman,  46  ; 
Carpenter,  Virchow,  47 ;  Lionel 
Beale,  Tyson,  49  ;  of  dentinal  pulp, 
134  ;  of  enamel,  117  ;  dentine, 
125 ;  cementum,  129  ;  follicular 
sac,  126. 
Celluloid,  893 ;  preparation  and  com- 
position, 893,  894  ;  manipulation, 
894-907. 
Celluloid  heaters  and  apparatus ;  for 
steam,  896  ;  for  oil  or  glycerine, 
897;  "Best"  for  moist  air,  899; 
Campbell's,  900;  Seabury's,  900; 
Evans',  900;  drying  cast  and  in- 
vestment, 903  ;  irritating  gum 
membrane-stippling,  905 ;  metal 
casts  and  deep  undercuts,  905, 
910  ;  liquid  celluloid,  907  ;  repair- 
ing, 906 ;  new  mode  continuous 
gum,  908;  Genese's  method,  909  ; 
finishing,  912  ;  cause  of  imperfec- 
tions, 913  ;  zylonite,  913. 
Cementation  process  for  refining  gold, 

691. 
Cementum,  origin-,  formation,  and  struc- 
ture, 129  ;  Magitot's,  Robin's,  Kcil- 
licker's,  Waldeyer's,  Hertz's,  KoU- 
man's  views,  129,  130,  147. 
Ceramic  art,    dental,   765,  915  ;  mate- 
rials and  processes,  914. 
Ceramo  plastic  work,  818. 


INDEX. 


987 


Characteristics  of  the  lips,  256;  of  the 
teeth,  176;  of  the  tongue,  258. 

Charcoal  as  fuel,  691,  940 ;  ingot 
mould,  699  ;  for  soldering,  774. 

Chemical  abrasion  of  teeth,  328. 

Cheoplastic  metal,  history,  820. 

Chloral-hydrate,  580. 

Chloride  of,  gold,  690  ;  zinc,  438. 

Chloroform,  tor  sensitive  dentine,  291 ; 
use  in  extraction,  574. 

Clamps,  for  swaging,  737  ;  for  solder- 
ing, 801. 

Clasps ;  value  and  conditions  of  use, 
638,  781 ;  teeth  suitable  for,  782 ; 
shaping  and  adjusting,  783 ;  method 
of  Fogle,  785 ;  Noble,  786  ;  Spald- 
ing, 787 ;  Austen,  787 ;  gold  for 
vulcanite  plates,  839. 

Clasp  plates,  shape  of,  789  ;  for,  inci- 
sors, 790 ;  six  front  teeth ;  bicuspids, 
792  :  ten  teeth,  793 ;  alternate 
spaces,  794. 

Classitication  of  teeth  ;  anatomical,  106; 
structural,  137;  pathological,  176  ; 

Cleft  palate,  accidental,  944,  970  ;  con- 
genital, 945,  950. 

Cobalt,  oxide  of;  action  on  dental  pulp, 
288 ;  coloring  material  for  porce- 
lain. 916. 

Cohesive  gold  foil,  479. 

Coke,  as  fuel,  691,  940. 

Coloring  materials   for  porcelain,  916. 

Combination  of  vulcanite  with  metal  for 
dental  plates,  885. 

Condensing  instruments  used  in  filling 
teeth,  468. 

Congelation  as  an  anaesthetic,  581. 

Continuous-gum  work,  807 ;  history, 
808;  properties,  809;  composition, 
810 ;  swaging  and  backing,  812  ; 
applying  gum  and  baking,  813. 

Contour  fillings,  516. 

Copper,  as  alloy,  for  gold,  695 ;  for 
zinc  and  tin,  733. 

Corallite,  838. 

Corundum  points,  416  ;  wheels,  760. 

Counter  dies,  732  ;  fusible  and  type- 
metal,  733  ;  lead,  732  ;  partial,  737. 

Creasote,  use  in  nerve  operation,  273. 

Crown  of  tooth  ;  artificial,  647  ;  build- 
ing up,  with  cohesive  or  sponge 
gold,  516 ;  excising,  for  pivot 
tooth,  647. 

Crucibles,  Hessian,  691. 

Crucing,  or   biscuiting  porcelain,  918. 

Crusta  petrosa,  129. 

Crystal,  or  sponge  gold,  483  ;  instru- 
ments and  manner  of  using,  484, 

Cuticula  dentis,  122. 

Cylinder  filliog,  473. 

Cystic  diseases,  233. 

Cytoblast,  43. 


DEEP-SEATED  caries,  treatment 
of,  428. 

Defects  of  the  palatine  organs,  944. 

Dental,  caries.  334;  treatment  of,  406; 
chair,  527  ;  engines,  450 ;  follicle, 
118,  129;  groove,  117;  porcelain, 
914;  prosthesis,  627;  pulp,  134; 
diseases  of,  262  ;  surgery,  361. 

Dentes  sapientiae,  112;  time  of  erup- 
tion, 172 ;  extraction  of,  561 ; 
irregularity  of,  870. 

Dentigerous  cysts,  233. 

Dentinal  tubuli,  141. 

Dentine,  140;  origin  and  formation,  125. 

Dentition,  162. 

Dentifrice,  Harris's  formula^,  348. 

Denuding  of  the  teeth,  327. 

Destruction  of  pulp,  283, 

Diamond  drill,  766. 

Dies  and  counter- dies,  724;  fusible 
metal,  730  ;  dipping  process,  725  ; 
sand  moulding,  726  ;  full  councer- 
dies,  730;  partial,  731 ;  metals  and 
alloys  suitable  for,  730, 

Diflferences  between  temporary  and 
permanent  teeth,  113. 

Dilaceration,  359. 

Diseases  of  dental  pulp,  262  ;  of  denti- 
tion, 163;  ofmucous  membrane,  182. 

Disks  for  cutting  teeth  structures,  etc. 
415. 

Dislocation  of  lower  jaw,  590. 

Draw  plate,  702. 

Drills,  for  excavating  teeth,  447;  for 
laboratory  use,  766. 

Drying  cavities  in  iJeeth,  458. 

Ducts,  salivary,  95. 

ELECTRIC  mouth  lamp,  443. 
Electro-magnetism,  as  an  anees- 

thetic,  583. 
Electro-magnetic  mallet,  488,  489. 
Elephant  ivory,  for  dentures,  633. 
Elevators  for  extracting  roots,  564. 
Emery  wheels,  764;  cloth,  825. 
Enamel:    origin   and   formation,    117; 

organ,  121  ;  characteristics,     137  ; 

chisels  for  cutting,  411. 
Engine  mallets  and  pluggers,  487,  488. 
Epithelial  process  or  band,  118. 
Epulis,  224. 

Erosion  of  the  teeth,  334. 
Eruption,  of  deciduous  teeth,  163  ;  of 

permanent  teeth,  172. 
Ether,  as  an  anassthet'C,  574. 
Ethics  of  dentistry   (see  Introductory 

Chapter),  23. 
Excavators,  446. 
Excising  forceps,  648. 
Exfoliition  of  alveolar  ridge,  306. 
Exostosis  of  teeth,  324. 
Explorers,  445. 


988 


INDEX. 


Exposed  pulps,  270;  destruction  of, 
283  ;  extirpation,  283  ;  filling  over 
and  treatment  of,  528. 

Extraction  of  teeth,  542 ;  temporary 
teetb,  570  ;  roots,  563  ;  teeth  and 
roots  for  artificial  work,  644 ; 
instruments  of— key,  547  ;  forceps 
(see  Forceps)  549. 

FACE  of  an  embryo,  58. 
Farrar's  syringe,  301. 

Fauces,  81. 

Feldspar,  915  ;  composition  of  contin- 
uous gum,  810;  porcelain,  915. 

Fibres,  muscular,  70. 

Fifth  pair  of  nerves,  87. 

F  le  carrier?,  413,  414. 

Files,  separating,  410;  V-shaped,  413, 
for  linishiDg  filling,  490  ;  vulcanite; 
872. 

Filing  teeth,  495. 

Filling  teeth,  407-495  ;  materials  :  gold, 
non-cohesive  foil,  430 ;  cohesive 
foil,  430;  crystal  or  sponge,  431; 
tin  foil,  432  ;  amalgam,  433  ;  gutta- 
percha, Hill's  stopping,  437;  zinc 
preparations,  438  ;  textile  metallic 
filling,  436. 
formation  of  cavity,  455  ;  separation 
of  teeth,  419;  excluding  moisture, 
saliva  pump,  459  ;  drying  cavities, 
458  ;  rubber  dam,  458. 
introducing  gold  ;  non- cohesive  foil, 
470 ;  roll,  rope,  or  band,  471  ; 
cylinders,  473;  pellets,  479;  co- 
hesive foil,  479  ;  heavy  foil,  482  ; 
crystal  or  sponge  gold,  483. 
condensation  with  mallet,  485  ;  finish- 
ing with  files,  491  ;  burnishing, 
493;  non-conductors  over  sensitive 
nerve,  528. 
filling  special  cavities :  in  superior 
incisors  and  cuspids,  496  ;  superior 
bicuspids  and  molars,  504  ;  inferior 
incisors  and  cuspids,  511  ;  inferior 
bicuspids  and  molars,  513 ;  con- 
tour tilling,  516. 
filling  over  expofed  or  sensiiive 
nerve,  493,  528  ;  method  of  Fos- 
ter, 530  ;  use  of  zinc  preparations, 
494;  Barrett's,  530;  King's,  531; 
Harris',  531;  Webb's,  533. 
filling  pulp  chamber  and  root-canal, 
535  ;  destruction  of  pulp  by  cautery 
and  by  arsenic,  284  ;  by  extirpa- 
tioo.  283  ;  method  of  Dunning, 
286;  Foster,  287;  Maynard,  287; 
Arthur,  Harris,  288  ;  Gorgas'  treat- 
ment of  cavity,  538  ;  instruments 
for  preparing  and  filling  pulp 
canals,  539. 
filling  over  exposed  pulps,  528. 


Finishing,  surface  of  fillingp,  491  ;  gold 
work,  775  ;  vulcanite  woik,  870. 

Fineness  of  gold,  697  ;  of  gold  solder, 
698  ;  formulas  and  tables  for  calcu- 
lation, 697. 

Fissure,  of  Glasserius,  68 ;  spheno- 
maxillary, pterygo  maxillary,  61. 

Flask,  moulding:  wooden,  Bailey's, 
Hawes",  728;  Watt's,  822;  West- 
on's, 823;  Reese's,  836;  Hayford's, 
837  ;  vulcanite,  861  ;  Kingsley's, 
for  palate,  983. 

Flask  press,  868. 

Flux  for  melting  and  soldering  gold, 
693,  758;  continuous  gum,  811; 
porcelain,  918. 

Fluids  of  the  mouth,  254. 

Foil  clipper,  480. 

Foil,  gold  (see  Filling),  470,  479;  tin, 
432. 

Follicle,  dental,  118. 

Follicular  sac  or  wall,  126. 

Foramen,  anterior  mental,  66  ;  infra- 
orbital, 65  ;  posterior  dental,  67  : 
posterior  palatine,  69  ;  stylo-mas- 
toid,  94. 

Forceps,  extracting  ;  for  molars,  Snell's 
Harris',  Wolverton's,  right  and 
left,  for  incisors  and  cuspids,  for 
wisdom  teeth,  550-556  ;  for  roots, 
Parmly's  alveolar,  with  screw, 
Maynard's,  etc.,  etc.,  557;  excis- 
ing, 648  ;  plate  cutting,  770  ;  punch, 
769  ;  Mallett's,  769. 

Formulas  for,  Harris'  mouth-wash,  211; 
alloying  gold,  697  ;  gold  solder, 
698  ;  continuous  gum,  810  ;  porce- 
lain body  and  enamel,  917  ;  flux 
and  frit,  918. 

Fountain  drip  point  and  mouth  pro- 
tector, 418. 

Fracture  of  the  jaws,  593;  of  the  teeth, 
331. 

Frenum  linguee,  66. 

Fuel  and  furnaces  for  melting  gold, 
691 ;  for  porcelain,  813. 

Fungous  giowth  of  pulp,  281. 

Fused  teeth,  355. 

Fusible,  metal  for  dies,  733  ;  alloys, 
730. 

Fusibility  of  gold,  solder,  704  ;  of  tin, 
lead,  etc.,  730,  732. 

GANGLION  ;    Casserian,  87  ;   Mec- 
kel's ;  sub-maxillary,  90. 
Gangrene  of  the  mouth,  189. 
Gas  regulator,  858. 
Gauge-plate,  702. 
Geminous  teeth,  355. 
Generation,  spontaneous,  46,  50. 
Germinal  matter  ;  synonyms,  49  ;  char- 
acteristics, 50. 


INDEX. 


989 


Gingivitis,  203. 

GlandiJ,  salivary  ;  parotid,  95  ;  submax- 
illary, 97  ;  sublingual,  98  ;  mucous, 
98. 

Gold,  for  filling  teeth ;  foil,  429,  470 ; 
crystal  or  sponge,  431  ;  for  base 
plate ;  value,  700 ;  necessity  and 
effect  of  alloys,  694 ;  refining,  by 
nitric  acid  process,  by  aqua  regia 
process,  by  cementation  process, 
by  fire,  689  ;  pouring  ingot,  ingot 
moulds,  698  ;  rolling  mills,  700 ; 
gauge  and  draw  plates,  tube  wire, 
702 ;  spiral  springs,  702  ;  solder, 
703  ;  soldering,  748  ;  teeth  attached 
to,  by  vulcanite,  886 ;  clasps  for 
vulcanite,  884 ;  oxide  of,  for  porce- 
lain gum  color,  917;  Reese's  gold 
alloy  cast  base,  832. 

Gorgas'  impromptu  interdental  splints, 
595. 

Green  stain  on  teeth,  252. 

Grinding  porcelain  teeth,  764. 

Groove,  dental,  117. 

Gum  lancets,  559  ;  teeth,  759  ;  single, 
766  ;  blocks  or  sections,  924. 

Gums,  anatomy,  103  ;  general  path- 
ology, 196;  inflammation,  203;  hy- 
pertroph}^,  212 ;  mercurial  inflam- 
mation, 214;  ulceration,  217;  ad- 
hesion to  cheek,222 ;  tumors  of,223. 

Gutta-percha,  over  sensitive  nerve,  528  ; 
for  filling  teeth,  437  ;  for  impres- 
sions, value  of,  710  ;  for  impression 
cups,  708 ;  for  articulating  rims, 
743  ;  for  palate  models,  980  ;  for  a 
base,  838. 

HAMMER,  wood,  horn,  or  lead,  for 
first  swaging,  iron,  for  final  swag- 
ing, 736. 

Hand-lathes,  761. 

Hand  pieces  for  dental  engine,  452. 

Hard  rubber  (see  Vulcanite),  839. 

Harris'  dentifrice,  348 ;  mouth- wash, 
211. 

Hayford's  alloy  and  press,  837. 

Heavy  gold  foil,  482. 

Hemorrhage  after  extraction,  571. 

Herbst  method  of  filling  teeth,  477. 

Hickory  wood  for  pivots,  650. 

Hill's  stopping,  437. 

Hippopotamus  ivory,  633. 

Hollow  wire,  656,  701. 

Hook  for  extracting  roots,  564. 

Human  teeth  attached  to  artificial  plate, 
631. 

Hydrate  of  chloral,  580. 

Hydrochlorate  of  cocaine,  586. 

Hydrostatic  blow-pipes,  748. 

Hypertrophy  of  cementum,  324 ;  of 
gums,  212;  of  walls  of  alveoli,  313. 


IMPRESSION  CUPS:  metallic,  705; 
Franklin's,  705;  gutta-percha,  hard 
rubber,  porcelain,  707  ;  Bean"s, 
712  ;  Fouke's,  706  ;  Wardle's,  705  ; 
swaged,  707. 
materials  ;  properties  and  classi- 
fication, 708 ;  beeswax  and  com- 
pounds, 709  ;  gutta-percha,  710  ; 
plaster,  711  ;  modeling  com- 
position, 711 ;  comparative  value, 
715. 

Impressions:  methods  of  taking,  713; 
preparation  for  model,  714;  re- 
moval from  model,  722;  for  vul- 
canite, 839;  for  obturator,  964;  for 
artificial  palate,  977. 

Incorruptible  teeth,  633. 

India-rubber,  839  ;  for  regulating  teeth, 
378  ;  for  separating  teeth,  419  ;  sul- 
phurated, 839. 

Inferior  maxilla,  65 ;  dislocation  and 
fracture  of,  590 ;  protrusion  of, 
404. 

Inflammation  of,  gums,  203  ;  deutal 
pulp,  265  ;  periosteum,  293  ;  max- 
illary sinus,  597. 

Ingot,  method  of  pouring,  and  moulds  ; 
iron,  soapstone,  charcoal,  698. 

Injuries  of  teeth  from  mechanical  vio- 
lence, 331. 

Insertion  of,  artificial  teeth  (organic 
prosthesis),  different  methods  o''. 
636;  gold  in  dental  cavities  (struc- 
tural prosthesis),  different  methods 
of,  470. 

Instruments  for,  forming  cavities  in 
teeth,  445  ;  introducing  gold.  470  ; 
finishing  fillings.  491 ;  nerve-opera- 
tions, 540  ;  manner  of  using,  541 ; 
for  extraction  of  teeth,  546  ;  roots. 
563. 

Inter-  or  pre-maxillary  bones,  60. 

Interdental  splints,  595. 

Interglobular  spaces  of  dentine.  147. 

Intertubillar  substance  of  dentine, 
141. 

Investment,  of  plaster  preparatory  to 
backing  teeth,  asbestos  (cr  sand) 
and  plaster,  preparatory  to  solder- 
ing, 772. 

Irregular  arrangement  of  artificial  teeth, 
766. 

Irregularity  of  natural  teeth,  in  form, 
350;  osseous  union,  354;  super- 
numerarj'-  teeth,  355 ;  third  den- 
tition, 173  ;  in  arrangement,  363  ; 
treatment  and  apparatus  for,  363  ; 
use  of  vulcanite  for,  383. 

Irritation  of  dental  pulp,  263. 

JARVIS'  separators,  422. 
Jointing  blocks,  767. 


990 


USTDEX. 


KAOLIN,  916;    nse   in  continuous- 
gum,    810 ;    in   dental   porcelain, 
916. 
Key  of  Garengeot,  546. 

LAMPS:  soldering,  749;  vulcamzing, 
901. 

Lancing  the  gums,  166 

Lands'  cross-pin  teetb,  920. 

Lathes  for  grinding  teeth,  etc. ;  hand 
and  font,  761. 

Lead,  for  filling  cavities  in  teeth,  432 ; 
for  counter-dies,  729 ;  alloys  of, 
730 ;  effect  of  antimony,  731 ;  for 
swaging- hammer,  736. 

Liability  of  teeth  to  decay,  336. 

Ligament,  external  lateral,  spheno- 
maxillary, stylo- maxillary.  68. 

Lining  root  canal  with  gold,  535. 

Lips,  symptomatology  of,  256. 

Loop  matrices,  509. 

Lower  jaw,  excess  of  teeth  in.  protru- 
sion, 401;  disbcation,  590;  frac- 
ture, 593. 

MAGNET,  for  refining  gold  filings, 
692. 
Magnetism,  electro-,  as  an  anaesthetic, 

583. 
Malformed  teeth.  350. 
Malleability  of  gold.  430,  687. 
Mallet,  force  in  condensation  of  gold, 
485  ;  hand  and  automatic,  485,  486 ; 
engine  pluggers,  486,  487. 
Mandrels,  416. 
Manganese,  oxide  of;  coloring  material 

of  pwcelain,  917. 
Manufacture  of  porcelain  teeth,  918. 
Materials;  for  filling  teeth,  429;  used 
as  dental  substitutes,  631 ;  for  im- 
pressions, 705 ;  for  swaged  plates, 
687  ;  for  plastic  or  moulded  plates, 
816  ;  for  dental  porcelain,  915. 
Matrices  for  filling  teeth,  509,  510. 
Matrix  of  bone,  56;  sand,  for  dies,  726; 
brass,    for    mou'ding    teeth,    918 ; 
plaster,  for  moulding  blocks,  936. 
Maxilla,  superior,  61 ;  inferior,  65  (see 

Lower  Jaw). 
Mechanical  abrasion  of  teeth,  330. 
Mechanics,  or  mechanism  of  dentistry ; 

classification,  625. 
Meckel's  cartilage,  59. 
Membrana  eboris,  127. 
Membrana  preformativa,  122,  126. 
Mercurial  stomatitis,  193  ;  inflammation 
of  gums,  203  ;  amalgam,  433  ;  ac- 
tion of  vulcanite,  841. 
Metallic    impression    cups;    britannia, 
swaged,    copper,    705 ;     dies    and 
counter-dies  (see  dies),  724 
Metallo-plastic  work,  819;  cheoplastic, 


820  ;  stanno-plastic,  821  ;  alumino- 
plastic,  831. 

Metals,  for  filling  teeth,  430  ;  for  swaged 
plates,  687;  for  plastic  plates,  816; 
for  dies  and  counter-dies,  724. 

Methylene,  bichloride  of,  580. 

Miller's  experiments  on  acids,  343. 

Model,  plaster,  718;  different  forms  of 
for  swaging,  719;  vulcanite,  843; 
sectional  model,  Westcott's,  721  ; 
Bean's,  722;  articulating,  742. 

Molecular  force,  46. 

Moulded  plates  of  plastic  materials,  816. 

Moulding-flasks,  726 ;  sand,  spatula, 
727. 

Mouth,  anatomy  and  physiology  of,  54; 
bones,  55  ;  muscles,  70  ;  blood  ves- 
sels, 82  ;  nerves,  87  ;  glands,  95  ; 
mucous  membrane,  100  ;  mirrors, 
442  ;  fluids  of,  97,  254  ;  relations  of, 
105;  washes,  210;  treatment  of 
preparatory  to  artificial  work,  648  ; 
impression  of,  713. 

Mucous,  membrane  of  mouth,  100;  dis- 
eases, 182;  deposit  on  teeth,  252. 

Muscles  of  the  mouth  and  face,  70 ; 
classification  of,  71. 

l^ASMYTH'S  membrane.  122. 

±M  Necrosis  of  alveolar  walls,  306  ; 
of  the  teeth,  321. 

Nerve,  exposed ;  filling  over.  528  ;  and 
instruments  for.  540 ;  destruction 
and  removal  of,  283  ;  inflammation 
of,  265  ;  nerve  broaches,  539. 

Nei'ves  of  the  mouth  and  face  ;  fifth  pair 
(trigemini),  87;  ophthalmic  branch- 
es, superior  maxillary  branches,  88, 
89;  inferior  maxillary  branches,  91 ; 
facial  nerve  (portio  dura  of  the  sev- 
enth pair)  and  branches,  92. 

Nitrate  of  potash  for  refining  gold,  689. 

Nitric  acid  process,  689. 

Nitro- muriatic  acid  process,  689. 

Nitrous  oxide  gas  and  apparatus,  for 
angesthesia,575;  as  a  blowpipe,  755. 

Nitrous  oxide  liquified,  577. 

Nodular  teeth,  357. 

Non  cohesive  gold,  470. 

Non  conductors  in  fillings,  493. 

Nucleolus  and  nucleus  of  cell,  develop- 
ment of,  43,  46. 

OBTtjBATOR,  961 ;  Delabarre's  for 
hard   palate,  963;    Kingsley's   for 
soft  palate,  964  ;  taking  impression 
for,  964  ;   combined  with  artificial 
palate,  974. 
Odontalgia,  273. 
Odontaiiopia.  315. 
Odontitis,  265. 
Odontomes,  357. 


INDEX. 


991 


Operations  in  organic  p'osthesis,  625  ; 
in  structural  prothesis,  406. 

Organic  prosthesis,  or  replacement  of 
dental  organs.  625. 

Origin  and  formation  of  teeth.  115  ;  of 
salivary  calculus,  240;  of  the  per- 
manent teeth,  130. 

Os  artificiel,  439. 

Osseous  union  of  teeth,  354. 

Ossification  of  dental  pulp,  282. 

Osteolog}-,  55. 

Oiteo-dentine,  149. 

Osteo-sarcoma,  223. 

Outline  form  of  partial  plates,  790. 

Oxidation  of  eighteen  carat  gold,  687  ; 
of  tin  alloy,  819. 

Oxide  of  cobalt,  288  :  gold,  manganese, 
titanium  and  uranium,  917. 

Oxychloride  of  zinc,  438. 

Oxyphosphate  of  zinc,  439. 

PACKING  vulcanite,  862. 
Palate,   hard,  68 ;  soft,  81 :  mus- 
cles of.  79. 

Palates,  artificial,  965;  Kingsley's.  966- 
983  :      Steam's,     970-979 ;     Sere- 
comb's  principle,  968. 
for  accidental  loss,  Kingsley's  case 

first,  966  ;  case  second,  967. 
for  congenital  fissure,  970:  ease  first, 
973  ;  case  second,  974:  case  third, 
975:  features  common  to  all,  975  : 
combined  with  staphylorraphy,  976. 
Kingsley's  method  of  constructing: 
impression,  977  ;  model,  978  ;  gutta- 
percha pattern,  979  ;  matrix  made 
of  plaster,  980 :  made  of  type- 
metal,  981 ;  improved  forms  of 
matrix,  982. 

Palatine  organs,  defects  of:  acc'dental. 
944 :  treatment  by  obturators  and 
artificial  palates,  961  ;  by  staphy- 
lorraphy, 948. 
congenital :  nature  and  development 
of,  945  ;  effect  on  mastication  and 
deglutition,  946  ;  on  vocal  articula- 
tion, 948  ;  treatment  by  staphylor- 
raphy, 948:  by  obturators  and  arti- 
ficial palates,  961-982. 

Palladium  for  base-plates.  812. 

Paning  (or  peening)  gold  band  for  rim- 
ming or  backing,  887. 

Papillae,  of  tongue,  circumvallate,  fun- 
giform, 99 ;  dental.  125. 

Parafiine  with  wax.  for  impressions, 
109. 

Parotid  gland,  95. 

Partial,  counter  dies,  737 ;  clasps  or 
stays,  638,  781;  plates:  dies  for, 
794  ;  swaging,  735  :  outline  forms, 
790 ;  retention  of.  779 ;  of  vulca- 
nite, 889  ;  of  stannic  alloys,  819. 


Pellets,  479. 

Periodontitis,  293. 

Periosteum,  alveolo-dental,  103;  sup- 
puration of,  297. 

Periostitis,  alveolar,  293. 

Permanent  teeth,  107  ;  extraction  of, 
542  :  separation  of  teeth,  424. 

Phosphor-necro-is   308. 

Phvsiognomv,  importance  of  aesthetic 
"  study  of,  924. 

Physiological  relations  of  the  mouth, 
105. 

Pickling  gold  plate,  to  remove  borax, 
775 :  lead  and  other  swaging 
metals,  738;  surface  alloy,  777. 

Pivot  teeth :  value  and  conditions  of 
use,  636 ;  excision  of  crown  for, 
647;  treatment  of  pulp,  648;  selec- 
tion of  crown,  650 ;  wooden  pivot, 
652 ;  metallic  pivot,  653  ;  Law- 
rence's method,  653  ;  Foster's 
method,  654;  Bean's  method, 
•556:  Richardson's  method,  673: 
Register's  method,  674,  682  :  Bish- 
op's method,  674;  Dwinelle's 
method,  675;  Morrison's  method, 
675;  Talbot's  method,  676;  Rich- 
mond's method,  676:  Buttner's 
method,  677  ;  Thomas'  method, 
658:  Bridge  work.  678;  Litch's 
method,  679:  Webb's  method, 
681  ;  Williams'  method,  685. 

Plaster,  calcined  :  for  impressions,  720 : 
manner  of  using,  718  :  comparative 
value,  716  ;  for  models,  720  ;  for 
temporary  investing  band,  after 
grinding  teeth.  767,  975 ;  for  sol- 
dering batter,  602. 

Plastic  work,  816  :  ceramo-plastic,  818, 
942  :  cheoplastic,  820  :  stanno-pla%- 
tic,  819  ;  alumino-plastic,  829  ;  vul- 
cano-plastic,  837. 

Plate,  swaged  for  dental  base  :  classifi- 
cation, swaging,  735 ;  adjusting 
teeth  to,  759 ;  articulating,  740 : 
soldering  teeth  to,  748 ;  compari- 
son of  different  kiud-j,  806. 

Platina,  as  alloy  of  gold,  688  :  precipi- 
tation of.  692 :  backings  fur  gold- 
plate,  773 ;  for  ordinary  swaged 
plate,  771 ;  for  continuous-gum 
work,  812;  sponge  for  coloring 
porcelain.  917  ;  pins  for  teeth,  how 
inserted,  919;  White's  foot-shaped, 
919. 

Plugging  pliers,  471 ;  instruments  for 
sponge  gold,  for  use  with  mallet, 
468-491 ;  for   nerve   cavities,    540- 

i  541. 

i  Polishing  fillings,  491 ;  gold  plate,  776 

j  (see  Finishing). 

I  Polypus  of  antrum  and  jaw,  227. 


992 


INDEX. 


Porcelain  impression  cups,  707;  forms 
for  filling  cavities,  524 ;  plates, 
818,  942  :  materials,  915  ;  coloring 
materials,  916. 

Porcelain  teeth  633,  914;  kinds  of, 
634 ;  aesthetic  rules  for  selection 
of,  635 ;  variety  and  beauty  of, 
914 ;  requirements  of,  715  :  illus- 
trations of  different  styles  of,  922- 
987 ;  adjustment  to  metal  plates, 
759  ;  vulcanite  blor-ks.  929  ;  whole- 
sale manufacture  of,  918 ;  in  blocks 
carved  for  special  cases,  935,  936. 

Portio  dura  of  the  seventh  pair  (facial 
nerve),  92. 

Potassium,  bromide  of,  to  deaden  sen- 
sibility of  fauces,  954. 

Preparation,  of  nerve  cavity  and  root 
for  filling.  535 :  of  mouth  for  arti- 
ficial work,  643:  of  root  for  artifi- 
cial crown,  647. 

Prevention  of  caries,  348. 

Piimary  curvatures  of  dentine,  142. 

Prismatic  cells  of  enamel,  119. 

Process :  alveolar,  64 :  malar,  nasal, 
63  ;  palate,  64  ;  mental,  66  ;  coro- 
noid,  condyloid,  processus  gracillis, 
67  ;  orbital,  65. 

Prosthesis  (see  Introductory  Chapter) 
of  structure,  428;  of  organs,  627  ; 
ethical  considerations,  629. 

Protection  against  explosion  of  vulcan- 
izers,  860  :  against  saliva,  458. 

Protoplasm,  48. 

Protrusion  of  lower  jaw,  401. 

Ptyaline,  99 

Pulp,  enamel,  117;  cavity,  filling  (see 
Nerve),  535. 

Pulp,  dental,  134:  diseases  of,  262; 
*  irritation,  263  :  inflammation,  265; 
fungous  growth,  281 ;  ossification, 
282  ;  treatment  of  exposed.  52H  ; 
destruction  and  removal  of,  283  ; 
action  of  arsenic  on,  285  ;  cobalt, 
oxide  of  zinc,  288. 

Pulpitis,  265. 

Pumice  for  dentifrice.  348  ;  for  support 
in  soldering,  757  ;  for  stanno- 
plastic  model,  822:  for  finishing 
vulcanite  plates,  871. 

Punch  for  marking  backings,  769  ;  for- 
ceps, 770 ;  for  extracting  roots, 
564. 

Purple  of  Cassius,  917. 

Purulent  engorgement  of  maxillary 
sinus,  597. 

Pus,  formation  of,  52. 

Pyrometer,  939. 

RAPID  breathing  as  a  pain  obtunder, 
586. 
Recipes,   for   dentifrice,    348 ;    mouth 


wash,  210;  alloying  gold  plate, 
694  ;  gold  solder,  703  ;  continuous 
gum,  807  ;  porcelain  body  and  en- 
amel, 917  :  flux,  gum  frit,  and 
gum  enamel,  918. 

Reese's  gold  alloy  cast  base,  832. 

Refining  gold  by  various  processes,  687. 

Relations  of  the  teeth  to  each  other,113. 

Repairing  continuous-gum  work,  807  ; 
stannic  alloys.  820;  vulcanite, 
874  :  alumino-plastic  work.  829. 

Replacement  of  teeth  (organic  prosthe- 
sis), 428;  order  of  operations,  625. 

Replantation  and  transplantation  of 
teeth,  587. 

Retention  of,  artificial  work,  636,  779 ; 
pivot,  636  ;  clasps,  638,  781  ;  spiral 
springs.  640,  779  ;  atmospheric 
pressure,  640,  796  :  adhesion  of 
contact,  799  :  vacuum   cavity,  802. 

Ring  socket,  for  excavators,  448 

Rob'nson's  textile  filling  material,  436. 

Rolling  mills,  700. 

Root,  orris,  for  dentifrice,  348. 

Roots  of  teeth,  filling  canals  of,  535  ; 
extraction  of,  563  ;  necessity  of  re- 
moval for  artificial  work.  643  :  pre- 
paration for  pivot  tooth,  647. 

Rubber-dam,  Barnum's,  460;  punches, 
461  ;  clamps,  464. 

Rubber,  India.  837;  bands  for  correct- 
ing irregularity,  363. 

SALIVA,  composition,  97  ;  function. 
97;  symp'omatology,  254;  pumps 
for  removal  of,  459. 

Salivary  calculus,  240 ;  glands  and  sa- 
liva, 95. 

Sand  moulding,  727  ;  with  plaster  for 
soldering  batter,  773. 

Sanguinary  calculus,  251. 

Scalers  for  removing  tartar,  250. 

Scorbutus,  194. 

Screw  for  roots,  564  ;  for  forceps,  566. 

Screws  for  retaining  fillings,  523. 

Secondary  dentine,  149. 

Second  dentition,  teeth  of,  168  ;  method 
of  directing,  363. 

Secretion,  nature  of,  53;  parotid,  97; 
submaxillary,  97. 

Selection  of  artificial  teeth,  766. 

Self-acting  blowpipes,  752. 

Sensitive  dentine,  289. 

Separation  of  the  teeth,  419. 

Shears,  plate.  735 

Shrinkage  of  metallic  dies,  732^  of 
porcelain  paste  in  baking,  918,  926. 

Silica  in  porcelain.  915. 

Silver,  as  alloy  of  gold,  698  ;  as  base- 
plate, 806  ;  use  in  composition  of 
cheoplastic  metal,  821. 

Sixth-year  molars,  369. 


INDEX. 


993 


Soapstone,  ingot  mould,  698;  powder 
with  pliister,  864. 

Socket  handles,  469  ;  ring,  448. 

Soft  palate  (see  Palate),  81. 

Solder,  gold,  703  ;  formulas,  704  ; 
burrs,  745  ;  for  aluminum,  831 ;  for 
vulcanite,  874. 

Soldering:  conditions  of  success,  748, 
756;  process,  758;  clamps  for,  756  ; 
lamps  for,  749  ;  blowpipes  for,  750; 
pan,  757;  preparations  of  clasps 
for,  785. 
teeth  to  backings,  769  ;  backings  to 
plate,  770 ;  double  plates,  801  ; 
carbon  cylinders  for,  754. 

Spar  (feldspar)  in  porcelain,  915; 
mixed  with  plaster,  787. 

Spiral  springs,  640,  702. 

Spontaneous  disorganization  of  pulp, 
280. 

Spray  apparatus  for  anaesthesia,  585. 

Springing  of  plates  in  soldering,  757. 

Stannic  (tin)  alloys,  for  metallic  dies, 
730  ;  for  base  plates,  819. 

Staphyloplasty,  957. 

Staphylorraphy,    948 ;     history,     951 
earlier   forms   of  operation,    952 
Fergusson's   first   operation,    952 
his  later  method,  955  :  Cartwright's 
preparation  of  patient,  953  ;  com- 
bination with  Kingsley's  artificial 
palate,  958 ;    comparison   of,  with 
mechanism,  960. 

Starr's  measuring  glass,  867. 

Steam  pressure,  859. 

Stellate  cells,  119. 

Steno,  duct  of,  96. 

Stomatitis,  182;  simple  or  catarrhal, 
184  ;  ulcerous,  185  ;  aphthous,  187; 
thrush,  188 ;  gangrene  of  the 
mouth,  189  :  mercurial,  193  ;  scor- 
butus scurvy,  194. 

Stomatoscopes,  442. 

Stratum  intermedium,  121. 

Student's  case  and  instruments,  526. 

Submaxillary  glands,  97. 

Sublingual  glands,  98. 

Substitutes  for  teeth ;  human  teeth, 
681  ;  teeth  of  cattle,  ivory,  632 ; 
porcelain,  633. 

Substitution,  or  replacement  of  teeth 
(organic  prosthesis),  627;  classifi- 
cation of  operations,  625. 

Sulphur,  combination  of,  with  gutta- 
percha, 838 ;  with  India-rubber, 
839  ;  action  on  vulcanizers,  860. 

Sulphuric  acid,  action   on   teeth,  341  ; 
process  for  refining  gold,  690 ;  for 
pickling  gold  plate,  775. 
Superficial  caries,  removal  of,  418. 
Superior  maxilla,  61. 
Supernumerary  teeth,  355. 

63 


Supplemental  teeth,  357. 

Swaged  work,  opei-ations  of  classified, 

627  ;  metals  used  for,  806. 
Swaging  process,  735. 
Syphilitic   teeth :    effects   of    syphilis, 

358. 
Syringe,  hypodermic,  581. 
Syringes,  mouth,  454,  459. 

TABLES  :  for  ascertaining  fineness 
of  gold,  697  ;  for  alloying  gold, 
697  ;  of  fusible  alloys,  730-731  ;  of 
fusibility  and  specific  gravity,  733  , 
of  steam  pressure  and  temperature; 
859  ;  of  time  and  temperature  in 
vulcanizing,  859. 

Tape  carrier,  492. 

Tartar  (see  Calculus),  240. 

Teeth :  anatomical  classification  and 
description,  106;  origin  and  form- 
ation, 115;  structure  of,  137. 
pathological  classification,  106  ;  dis- 
eases of,  264 ;  caries,  334  ;  filling 
(structural  prosthesis),  406  ;  ex- 
traction, 542 ;  irregularity,  368. 
replacement  of  loss  of  (organic  pros- 
thesis), 627;  substitutes  for,  631; 
methods  of  replacing,  647  ;  artic- 
ulation or  antagonism  of,  anatom- 
ical, 112  ;  prosthetic,  740  ;  suitable 
for  clasping,  781  ;  grinding  and 
adjusting  to  plate,  759  ;  manufac- 
ture of  porcelain,  -  914  ;  various 
forms  and   sesthetie  study  of,  918. 

Temperaments,    classification   of,    155. 

Temporary:  teeth,  107  ;  extraction  of, 
570  ;  investing  rims  of  plaster,  after 
grinding  teeth,  768. 

Temporo-maxillary  articulation,  81. 

Third  dentition,  173. 

Time  after  extraction,  for  insertion  of 
artificial  teeth,  646. 

Tin,  and  its  alloys :  for  swaging,  730  ; 
for  base  plates,  819. 

Tin-foil:  for  filling  teeth,  482;  for 
investing  impressions,  721  ;  for 
patterns  of  plate,  735  ;  for  tempo- 
rary articulating  plates,  and  for 
temporary  use  in  grinding  teeth, 
844. 

Titanium,  oxide  of,  for  coloring  porce- 
lain, 917. 

Tongue,  99  ;  svmptomatology  of,  258. 

Tonsils,  81. 

Tooth-ache  (Odontalgia),  273. 

Tooth  structures,  137. 

Transplantation  of  teeth,  589. 

Trephines  for  opening  antrum,  611. 

Trial  of  teeth  before  soldering,  773  ; 
unnecessary  after  correct  articu- 
lation, 844. 

Tube  wire,  702. 


994 


INDEX. 


Tumors  of  the  raoutli  and  jaws,  223  :  I 
cystic,  233.  i 

Type-metal :    for    metallic   dies,  763  ; 
for  Kingsley's  palate  matrix,  981. 

ULCERATION  of  the  gums,  217. 
Ulcerous  stomatitis,  185. 
United  teeth,  354. 

Uranium,  oxide  of,  for  coloring  porce- 
lain, 917. 
Uvula,  81 :  loss  of,  950,  966. 

VACUUM    cavity:     history,     802; 
form  and  position,  804,  805  ;  ob- 
jections to  use,  798. 

Varnishes  for  plaster  impressions  and 
models,  714,  865. 

Veins  of  the  mouth  and  face,  87. 

Vela,  artificial,  961. 

-Von  Bonhorst's  applicator,  585. 

Vulcanite,  839 ;  composition  and 
varieties  of,  840 ;  effect  of  the 
vermilion  in,  841  ;  impressions, 
842 :  models,  843  :  articulation, 
844  :  grinding  and  arranging  teeth, 
844 :  making  matrix  plate,  846 ; 
packing  and  preparing  flasks, 
865  ;  time  of  vulcanizing,  869  ;  re- 
moval from  flask  and  finishing, 
870;  repairs  of,  874;  Stuck' s 
method,  874 ;  Snow's  method, 
876. 
teeth  suitable  for,  845,  885,  886  ;  par- 
tial sets  and  gold  clasps  for,  884  ; 
attaching  teeth  to  metal  plates  by, 
885:  P.  G.  C.  Hunt's  method,  887; 
liquid  rubber  for  repairs,  889 ; 
spring  plates,  889  :  for  pivot  teeth, 
887 ;  for  correcting  irregularity, 
383,  891. 
durability   of,   891  ;   Goodyear' s  and 


other  patents,  839;  merits  and  de- 
merits of,  892. 

Vulcanizers;  Ward,  Campbell,  Seabury. 
Evans,  849-857:  Whitney,  Hays, 
Snowden  &  Cowman,  Edson, 
Wood,  flasks  for,  861,  862,  and 
flask  press,  868 ;  packing  boiler, 
865  ;  safety-gauge,  860. 
regulation  of  temperature  by  steam 
gauge,  857  ;  by  thermometer,  853  ; 
steam  high-pressure  tables,  859  : 
strength  of  vulcanizers,  860  :  time 
of  vulcanizing,  869. 

Vulcano-plastic  work,  837. 

WARPING  of  plates,  757,  772. 
Watts'  alloy,  821. 

Wax  :  for  impressions,  709  :  compara- 
tive value,  715;  for  articulating 
plates  and  rims.  741  ;  for  matrix 
plates,  846  ;  spatulas,  847,  848. 

Wedges  for  separating  teeth,  422, 

Wedgewood's  porcelain,  916. 

Westcott's  experiments  on  acids  and 
alkalies,  343. 

Weston's  fusible  metal,  821. 

Wharton's  duct,  97. 

Wheels  for  polishing,  776. 

Wood  polishing  points,  417. 

Wood's  metal  for  filling  and  base,  821. 

Wounded  pulps,  treatment  of,  272. 

ZINC  :  preparations  for  filling  teeth, 
438 ;  use  in  gold  solder  ;  for  metal- 
lic dies  made  by  pouring  in  im- 
pression, made  by  sand  moulding, 
887  :  contraction  of,  732  ;  advan- 
tages of,  for  die,  729. 

Zinc,  oxy-chloride,  438 ;  oxy-phos- 
phate,  439:  white  oxide  of,  for 
polishing,  871. 

Zj-lonite,  913. 


FEBRUARY,  1886. 

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Social  and  Moral  Relations.  By  William  Acton,  m.d.,  m.r.c.s.  Sixth  Edition. 
8vo.  Cloth,  $2.00 

AITKEN.  Science  and  Practice  of  Medicine.  By  William  Aitken,  m  d  f.r.s., 
Professor  of  Pathology  in  the  Army  Medical  School,  London.  Seventh  Edition. 
Revised  throughout.     iq6  Engravings  on  Wood,  and  a  Map.     2  vols.     8vo. 

Cloth,  $12.00;  Leather,  $14-00 

ALLBUTT.  Visceral  Neuroses.  On  Neuralgia  of  the  Stomach,  and  AlUed  Dis- 
orders. By  T.  Clifford  Allbutt,  m.d.,  f.r.s.,  Consulting  Physician  to  the 
Leeds  General  Infirmary.     8vo.  Cloth,  $1.50 

ALLEN.    Commercial  Organic  Analysis.    A  Treatise  on  the  Modes  of  Assaying 
the  Various  Organic  Chemicals  and  Products  employed  in  the  Arts,  Manufactures, 
Medicine,  etc.,  with  Concise  Methods  for  the  Detection  of  Impurities,  Adultera- 
tions, etc'     Second  Edition.    Revised  and  Enlarged.    By  Alfred  Allen,  f.C.S. 
Vol     I.    Alcohols,    Ethers,    Vegetable    Acids.    Starch   and    its   Isomers,    etc. 

$4.50 

Vol.  II.  Fixed  Oils  and   Fats,  Hydrocarbons  and  Mineral  Oils,  Phenols  and 

their  Derivatives,  Coloring  Matters,  etc.  In  Press. 

Vol.  III.  Cyanogen  Compounds,  Alkaloids,  Animal  Products,  etc.       In  Press. 

ALLEN'S  New  Method  of  Recording  the  Motions  of  the  Soft  Palate.     By  Harrison 

Allen,. m.d.,  Professor  of  Physiology  University  of  Pennsylvania.       Cloth,  .50 

ALLINGHAM.    Diseases  of  the  Rectum.    Fistula,  Hcemorrhoids,  Painful  Ulcer 

Stricture,  Prolapsus,  and  other  Diseases  of  the    Rectum,  their   Diagnosis  and 

Treatment.       By  William  Allingham,  f.r.c.s.      Fourth  Edition,    Enlarged. 

Illustrated.     Bvo.  Paper  covers,  .75  ;  Cloth,  $1.25 

London  Edition,  thick  paper  and  larger  type,  $2.00 
ALTHATJS.    Medical  Electricity.    Theoretical  and  Practical.    Its  Use  in  the  Treat- 
ment  of  Paralysis,  Neuralgia,  and  other  Diseases.     By  Julius  Althaus,  m.d. 
Third  Edition,  Enlarged.    246  Illustrations.     8vo.  Cloth,  $6.00 

ANSTIE.  Stimulants  and  Narcotics.  With  special  researches  on  the  Action  of 
Alcohol  Ether  and  Chloroform  on  the  Vital  Organism.  By  Francis  E.  Anstie, 
M.D.     8vo.  Cloth,  $3-oo 

ARLT.  Diseases  of  the  Eye.  Clinical  Studies  on  Diseases  of  the  Eye.  Including  the 
Conjunctiva,  Cornea  and  Sclerotic,  Iris  and  Cihary  Body.  By  Dr.  Ferd.  Ritter 
von  Arlt  University  of  Vienna.  Authorized  Translation  by  Lyman  Ware, 
M  D  Surgeon  to  the  lUinois  Charitable  Eye  and  Ear  Infirmary,  Chicago. 
Illustrated.     8vo.  Cloth,  $2.50 

ARMATAGE.  The  Veterinarian's  Pocket  Remembrancer.  Containing  concise 
directions  for  the  Treatment  of  Urgent  or  Rare  Cases,  embracing  Semeiology, 
Diagnosis,    Prognosis,    Surgery,  Therapeutics,  etc.     32mo.  Cloth,  $1.25 

BALFOUR.  Clinical  Lectures  on  Diseases  of  the  Heart  and  Aorta.  By  G.  W. 
Balfour,  m.d.     Illustrated.     Second  Edition.  Cloth,  $5.00 

BARNES.  Lectures  on  Obstetric  Operations,  including  the  Treatment  of  Hemor- 
rhage, and  forming  a  Guide  to  Difficult  Labor.  By  Robert  Barnes,  m.d., 
f.r.c.p.     Fourth  Edition.     Illustrated.     8vo.  Cloth,  $3.75 

5 


p.  BLAKISTON,  SON  &-  CO:S 


BARRETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
and  Dentistry.     Extraction  of  Teeth,  etc.     By  A.  W.  Barrett,  m.d.    Illustrated. 

Cloth,  $i.oo 

EARTH  AND  ROGER.  Auscultation  and  Percussion.  i2mo.  Cloth,  ^i.oo 
BARTLEY.  Medical  Chemistry.  A  Text-book  for  Medical  and  Pharmaceutical 
Students.  By  E.  H.  Bartley,  m.d..  Associate  Professor  of  Chemistry  at  the 
Long  Island  College  Hospital ;  President  of  the  American  Society  of  Public 
Analysts;  Chief  Chemist,  Board  of  Health,  of  Brooklyn,  N.  Y.  With  Illustra- 
tions, Glossary  and  Complete  Index.     i2mo.  Cloth,  $2.50 

BEALE.     On  Slight  Ailments ;  their  Nature  and  Treatment.     By  Lionel  S.  Beale, 

M.D.,  F.R.S.,  Professor  of  Practice,  King's   Medical    College,  London.     Second 

Edition.     Enlarged  and  Illustrated.  Paper  covers,  .75  ;  Cloth,  |;i.25 

Finer  Edition,  Heavy  Paper.  Extra  Cloth,  $1.75 

Urinary  and  Renal  Diseases  and  Calculous  Disorders.     Hints  on  Diagnosis 

and  Treatment.     Demi-8vo.     356  pages.  Cloth,  ^1.75 

The  Use  of  the  Microscope  in  Practical  Medicine.    For  Students  and 

Practitioners,  with  full  directions  for  examining  the  various  secretions,  etc., 

in   the  Microscope.     Fourth  Edition.     500  Illustrations.     8vo.     Cloth,  $7.50 

How  to  Work  with  the  Microscope.     A  Complete  Manual  of  Microscopical 

Manipulation,    containing   a   full    description    of  many   new   processes    of 

■     investigation,    with    directions    for    examining   objects   under   the    highest 

powers,  and  for  taking  photographs  of  microscopic  objects.     Fifth  Edition. 

Containing  over  400  Illustrations,  many  of  them  colored.     8vo.     Cloth,  $7.50 

Protoplasm  ;  or  Matter  and  Life.  Sixteen  Colored  Plates.  Part  I.  Dissen- 
tient.    Part  II.    Demonstrative.     Part  III.    Suggestive.    New  Ed.  Preparing. 

Bioplasm.  A  Contribution  to  the  Physiology  of  Life,  or  an  Introducdon  to  the 
Study  of  Physiology  and  Medicine,  for  Students.  With  numerous  Illus- 
trations. ■  Cloth,  $2.25 

Life  Theories  ;  Their  Influence  upon  Religious  Thought.    Six  Colored  Plates. 

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One  Hundred  Urinary  Deposits,  on  eight  sheets,  for  the  Hospital,  Labora- 
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BEASLEY'S  Book  of  Prescriptions.  Containing  over  3100  Prescriptions,  collected 
from  the  Practice  of  the  most  Eminent  Physicians  and  Surgeons — English, 
French  and  American  ;  a  Compendious  History  of  the  Materia  Medica,  Lists  of 
the  Doses  of  all  Officinal  and  Established  Preparations,  and  an  Index  of  Diseases 
and  their  Remedies.  By  Henry  Beasley.  Sixth  Edition.  Revised  and 
Enlarged.  Cloth,  #2.25 

Druggists'  General  Receipt  Book.  Comprising  a  copious  Veterinary  Formu- 
lary ;  Recipes  in  Patent  and  Proprietary  Medicines,  Druggists'  Nostrums, 
etc.;  Perfumery  and  Cosmetics  ;  Beverages,  Dietetic  Articles  and  Condi- 
ments ;  Trade  Chemicals,  Scientific  Processes,  and  an  Appendix  of  Useful 
Tables.     Ninth  Edition.     Revised.  Cloth,  $2.25 

Pocket  Formulary  and  Synopsis  of  the  British  and  Foreign  Pharmacopoeias. 
Comprising  Standard  and  Approved  Formulae  for  the  Preparations  and 
Compounds  Employed  in  Medical  Practice.    Eleventh  Edition.    Cloth,  $2.25 

BENTLEY  AND  TRIMEN'S  Medicinal  Plants.  A  New  Illustrated  Work,  con- 
taining full  botanical  descriptions,  with  an  account  of  the  properties  and  uses  of 
the  principal  plants  employed  in  medicine,  especial  attention  being  paid  to  ihosc 
which  are  officinal  in  the  British  and  United  States  Pharmacopoeias.  The  plants 
which  supply  food  and  substances  required  by  the  sick  and  convalescent  are  also 
included.  By  R.  Bentley,  f.r.s.,  Professor  of  Botany,  King's  College,  London, 
and  H.  Trimen,  m.b.,  f.h.s.,  Department  of  Botany,  British  Museum.  Each 
species  illustrated  by  a  colored  plate  drawn  from  nature.  In  forty-two  parts. 
Eight  colored  plates  in  each  part. 

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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  7 

BIBLE  HYGIENE ;  or  Health  Hints.  By  a  physician.  Written  to  impart  in  a 
popular  and  condensed  form  the  elements  of  Hygiene;  showing  how  varied  and 
important  are  the  Health  Hints  contained  in  the  Bible,  and  to  prove  that  the 
secondary  tendency  of  modern  Philosophy  runs  in  a  parallel  direction  with  the 
primary  light  of  the  Bible.     i2mo.  Cloth,  $i.oo 

BIDDLE'S  Materia  Medica  and  Therapeutics.    Tenth  Edition.    For  the  Use  of 

Students  and  Physicians.  By  Prof.  John  B.  Biddle,  m.d.,  Professor  of  Materia 
Medica  in  Jefferson  Medical  College,  Philadelphia.  The  Tenth  Edition,  thor- 
oughly revised,  and  in  many  parts  rewritten,  by  his  son,  Clement  Biddle,  m.d., 
Assistant  Surgeon,  U.  S.  Navy,  and  Henry  Morris,  m.d.,  Demonstrator  of 
Obstetrics  in  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  of 
Philadelphia,  etc.  The  Botanical  portions  have  been  curtailed  or  left  out,  and 
the  other  sections,  on  the  Physiological  action  of  Drugs,  greatly  enlarged. 

Cloth,  #4.00;  Leather,  ^.75 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons  by  Micro-Organisms.  A 
Biological  study  of  the  Germ  Theory  of  Disease.     By  G.  V.  Black,  m.d.,  d.d.s. 

Cloth,  $1.50 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
Charles  L.  Bloxam,  Professor  of  Chemistry  in  King's  College,  London,  and  in 
the  Department  for  Artillery  Studies,  Woolwich.  Fifth  Edition.  With  nearly 
300  Engravings.     8vo.  Cloth,  $3.75  ;  Leather,  #4.75 

Laboratory  Teaching.  Progressive  Exercises  in  Practical  Chemistry.  In- 
tended for  use  in  the  Chemical  Laboratory,  by  those  who  are  commencing 
the  study  of  Practical  Chemistry.     4th  Edition.     89  lUus.  Cloth,  ^1.75 

BOWMAN".  Practical  Chemistry,  including  analysis,  with  about  100  Illustrations. 
By  Prof.  John  E.  Bowman.  Eighth  English  Edition.  Revised  by  Prof.  Bloxam, 
Professor  of  Chemistry,  King's  College,  London.  Cloth,  $2.co 

BRAUNE.  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates, 
Photographed  on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other 
illustrations.  By  Wilhelm  Braune,  Professor  of  Anatomy  at  Leipzig.  Trans- 
lated and  Edited  by  Edward  Bellamy,  f.r.c.s.,  Lecturer  on  Anatomy,  Char- 
ing Cross  Hospital,  London.     4to.  Cloth,  $8.00  ;  Half  Morocco,  $10.00 

BRUBAKEH.  Physiology.  A  Compend  of  Physiology,  specially  adapted  for  the 
use  of  Students  and  Physicians.  By  A.  P.  Brubaker,  m.d.,  Demonstrator  of 
Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
Dental  Surgery,  Philadelphia.  Third  Edition.  Revised,  Enlarged  and  Illus- 
trated.    "  No.  4,  ?  Ouiz-Compend  Series  .f* "     i2mo.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  ^1.25 

BRUEN,  Physical  Diagnosis.  For  Physicians  and  Students.  By  Edward  T. 
Bruen,  m.d.,  Asst.  Professor  of  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania.    Illustrated  by  Original  Wood  Engravings.     i2mo.    2d  Ed.    Cloth,  $1.50 

BUCKNILL  AND  TUKE'S  Manual  of  Psychological  Medicine :  containing 
the  Lunacy  Laws,  the  Nosology,  Etiology,  Statistics,  Description,  Diagnosis, 
Pathology  (including  morbid  Histology)  and  Treatment  of  Insanity.  By  John 
Charles  Bucknill,  m.d.,  f.r.s.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p. 
Fourth  Edition,  much  enlarged,  with  twelve  lithographic  and  numerous  other 
illustrations.     8vo.  Cloth,  $8.00 

BTJLKLEY.  The  Skin  in  Health  and  Disease.  By  L.  Duncan  Bulkley,  m.d., 
Attending  Physician  at  the  New  York  Hospital.     Illustrated.  Cloth,  .50 

BURDETT'S  Pay  Hospitals  and  Paying  Wards  throughout  the  World.     Facts  in 

support  of  a  rearrangement  of  the  system  of  Medical  Relief.     By  Henry  C. 

Burdett,  m.d.     8vo.  Cloth,  $2.25 

Cottage    Hospitals.     General,    Fever    and    Convalescent;    their   Progress, 

Management  and  Work.     Second  Edition.     Rewritten  and  Enlarged,  with 

Plans  and  Illustrations.     Crown  8vo.  Cloth,  $4.50 

BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d.,  Prof, 
of  Diseases  of  the  Ear,  at  the  Philadelphia  Polyclinic.     Illustrated.        Cloth,  .50 


p.  BLAKISTON,  SON  <S-  CO:S 


BUZZARD.    Clinical  Lectures  on  Diseases  of  the  Nervous  System.    By  Thos. 

Buzzard,  ri.d.     Illustrated.     Octavo.  Cloth,  $5.00 

BYFORD.  Diseases  of  Women.  The  Practice  of  Medicine  and  Surgery,  as 
applied  to  the  Diseases  of  Women.  By  W.  H.  Byford,  a.m.,m.d.,  Professor  of 
Obstetrics  and  the  Diseases  of  Women  and  Children,  in  the  Chicago  Medical 
College.  Third  Edition.  Revised  and  Enlarged,  much  of  it  rewritten,  with 
numerous  additional  illustrations.     8vo.  Cloth,  $5.00;  Leather,  $6.00 

On  the  uterus.     The  Chronic  Inflammation  and  Displacement  of  the  Unim- 
pregnated  Uterus.     With  Illustrations.  Paper,  .75  ;  Cloth,  $1.25 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
M.D.,  F.R.s.  Sixth  Edition.  Revised  and  Enlarged,  with  over  500  Illustrations 
and  Lithographs.  Cloth,  $5.50 

CARTER.  Eyesight,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation 
of  Vision.  By  Robert  Brudenell  Carter,  f.r.c.s.  Second  Edition,  with  50 
Illustrations,  Test  Types,  etc.     i2mo.  Paper,  .75  ;   Cloth,  $1.25 

CAZEAUX  and  TARNIER'S  Midwifery.  Seventh  Revised  and  Enlarged  Edition. 
With  Colored  Plates  and  numerous  other  Illustrations.  The  Theory  and 
Practice  of  Obstetrics ;  including  the  Diseases  of  Pregnancy  and  Parturition, 
Obstetrical  Operations,  etc.  By  P.  Cazeaux,  Member  of  the  Imperial  Academy 
of  Medicine,  Adjunct  Professof  in  the  Faculty  of  Medicine  in  Paris.  Remodeled 
and  rearranged,  with  revisions  and  additions,  by  S.  Tarnier,  m.d..  Professor  of 
Obstetrics  and  Diseases  of  Women  and  Children  in  the  Faculty  of  Medicine  of 
Paris.  A  New  American,  from  the  Eighth  French  and  First  Italian  Edition. 
Edited  and  Enlarged  by  Robert  J.  Hess,  m.d..  Physician  to  the  Northern  Dis- 
pensary, Phila.,  etc.  About  iioo  pages  quarto,  with  12  Full-page  Plates  (five  of 
which  are  beautifully  colored)  and  over  175  Wood  Engravings.  Royal  Square 
Octavo.  So/d  by  subscription  only.  Circulars  and  information  will  be  sent,  upon 
application  to  the  Publishers. 

CHARTERIS.    The  Practice  of  Medicine.    A  Handbook.    By  M.  Charteris, 

M.D.,  Member  of  Hospital  Staff  and  Professor  in  University  of  Glasgow.     With 

Microscopic  and  other  Illustrations.  Cloth,  $1.25 

Materia  Medica  and  Therapeutics.    A  Manual  for  Students.         In  Press. 

CHAVASSE.  The  Mental  Culture  and  Training  of  Children.  By  Pye  Henry 
Chavasse.     i2mo.  Cloth,  ;^i.oo 

CHURCHILL.  Face  and  Foot  Deformities.  By  Fred.  Churchill,  m.d., 
Ass't  Surgeon  to  the  Victoria  Hospital  for  Sick  Children,  London.  Six  Plain 
and  Two  Colored  Lithographs.     8vo.  Cloth,  $3.50 

CLEAVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
correct  Pronunciation  and  Definition  of  terms  used  in  medicine  and  the  col- 
lateral sciences,  abbreviations  used  in  prescriptions,  list  of  poisons,  their  anti- 
dotes, etc.     By  C.  H.  Cleaveland,  m.d.     Thirty-first  Edition.     i6mo. 

Cloth,  .75;  Tucks  with  Pocket,  $1.00 

COBBOLD.  A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some 
account  of  the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  Illus- 
trations.    8vo.  Cloth,  $5.00 

COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
the  Apparatus  Employed,  etc.     By  J.  SoLis  Cohen,  m.d.     With  cases  and  Illus- 
trations.    A  New  Enlarged  Edition.     i2mo.  Paper,  .75  ;  Cloth,  $1.25 
The  Throat  and  Voice.    Illustrated.    i2mo.  Cloth,  ,50 

COLES.  Deformities  of  the  Mouth,  Congenital  and  Acquired,  with  Their  Me- 
chanical Treatment.  By  Oakley  Coles,  m.d.,  d.d.s.  Third  Edition.  83  Wood 
Engravings  and  96  Drawings  on  Stone.     8vo.  Cloth,  ^4.50 

The  Dental  Student's  Note-Book.    A  new  Edition.    i6mo.  Cloth,  $1.00 

COOPER'S  Surgical  Dictionary.  A  Dictionary  of  Practical  Surgery  and  Encyclo- 
paedia of  Surgical  Science.  By  Samuel  Cooper.  New  Edition.  By  Samuel 
A.  Lane,  f.r.c.s.,  assisted  by  various  eminent  Surgeons.     2  vols.      Cloth,  $12.00 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  9 

COOPER  on  Syphilis  and  Pseudo-Syphilis.  By  Alfred  Cooper,  f.r.c.s.,  Sur- 
geon to  the  Lock  Hospital,  to  St.  Marks,  and  to  the  West  London  Hospitals. 
Octavo.  Cloth,  #3.50 

CORMACK'S  Clinical  Studies.  Illustrated  by  Cases  observed  in  Hospital  and 
Private  Practice.  By  Sir  John  Rose  Cormack,  m.  d.,  k.  b.,  etc.  Illustrated. 
2  vols.  1 1 27  pp.  Cloth,  $5.00 

COURTY.  The  Uterus,  Ovaries,  etc.  A  Practical  Treatise  on  Diseases  of  the  Uterus, 
Ovaries  and  Fallopian  Tubes.  By  Prof.  A.  Courty,  of  Montpellier,  France. 
Translated  from  the  Third  Edition,  by  his  pupil  and  assistant,  Agnes  IMcLaren, 
M.D.,  M.K.Q.c.p.i.  With  a  Preface  by  J.  Mathews  Duncan,  m.d.,  ll.d.,  f.r.s., 
Obstetric  Physician  to  Saint  Bartholomew's  Hospital,  London,  With  431  Illus- 
trations.    8vo.     Sold  by  Subscription.        ■  Cloth,  ^6.00;  Leather,  ^7.00 

CRIPPS.  Diseases  of  the  Rectum  and  Anus,  including  a  portion  of  the  Jackson- 
ian  Prize  Essay  on  Cancer.  By  Harrison  Cripps,  m.d.,  Ass't  Surgeon  to  St. 
Bartholomew's  Flospital,  London.     Lithographic  Plates  and  other  Illustrations. 

Cloth,  $4.50 

CTILLINGWORTH.  A  Manual  of  Nursing,  Medical  and  Surgical.  By  Charles 
J.  CuLLiNGWORTH,  M.D.,  Physician  to  St.  Mary's  Flospital,  Manchester,  England. 
Second  Edition.     With  18  Illustrations.     i2mo.  Cloth,  $1.00 

A  Manual  for  Monthly  Nurses.    32mo.  Cloth,  .50 

CURLING.    On  the  Diseases  of  the  Testis,  Spermatic  Cord  and  Scrotum.    By 

T.  B.  Curling,  m.d.,  f.r.s.     Fourth  Edition,  Enlarged  and  Illustrated.     Svo, 

Cloth,  $5.50 

DAGUENET'S  Ophthalmoscopy.  A  Manual  for  the  Use  of  Students.  By  Dr. 
Daguenet.  I'ranslated  from  the  French,  by  Dr.  C.  S.  Jeafferson,  f.r.c.s.e. 
Illustrated.     i2mo.  Cloth,  $1.50 

DALBY.  The  Ear.  The  Diseases  and  Injuries  of  the  Ear.  By  W.  B.  Dalby,  m.d.. 
Surgeon  and  Lecturer  on  Aural  Surgery,  St.  George's  Hospital.  With  Illustra- 
tions.    i2mo.  Cloth,  ^1.50 

DAY.     Diseases  of  Children.    A  Practical  and  Systematic  Treatise  for  Practitioners 

and  Students.     By  Wm.  H.  Day,  m.d.     Second  Edition.     Rewritten  and  very 

mu^h  Enlarged.     Svo.     752  pp.     Price  reduced.  Cloth,  $3.00 ;  Sheep,  $4.00 

On  Headaches.     The  Nature,  Causes  and  Treatment  of  Headaches.     Fourth 

Edition.     Illustrated.     Svo.  Paper,  .75;  Cloth,  ^1.25 

DILLNBERGER.  On  Women  and  Children.  A  Handbook  of  the  Treatment 
of  the  Diseases  Peculiar  to  Women  and  Children.  By  Dr.  Emil  Dillnberger. 
121110.  Cloth,  ^1.50 

DOBELL.  On  Winter  Cough,  Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By 
Horace  Dobell,  m.d..  Senior  Physician  to  the  Royal  Hospital  for  Diseases  of 
the  Chest.     Third  Edition.     Octavo.  Cloth,  ^3.50 

DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
Ed.  J.  DomviUe,   m.d.    fifth  Ed.      With  Recipes  for  Sick-room  Cookery,  etc. 

Cloth,  .75 

DRUITT'S  Modern  Surgery.  The  Surgeon's  Vade  Mecum  ;  a  Manual  of  Modern 
Surgery.  By  Robert  Druitt,  f.r.c.s.  Twelfth  Enlarged  Edition,  with  369 
Illustrations.     864  pp.  In  Preparation. 

DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
Second  Edition,  Enlarged,  with  new  Illustrations.  Cloth,  .75 

DUNCAN,  On  Sterility  in  Women.    By  J.  Mathews  Duncan,  m.d.,  ll.d.,  Obstetric 

Physician  to  St.  Bartholomew's  Hospital,  etc.     Octavo.  Cloth,  $2.00 

DURKEE,  On  Gonorrhoea  and  Syphilis.  By  Silas  Durkee,  m.d.  Sixth  Edition. 
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ELLIS.     Diseases  of  Children.     A  Practical  Manual  of  the  Diseases  of  Children, 

with  a  Formulary.     By  Edward  Ellis,  m.d.     Late  Physician  to  the  Victoria 

Hospital  for  Children,  London.     Fourth  Edition,  Enlarged.  Cloth,  $3.00 

What  Every  Mother  Should  Know.     i2mo.  Cloth,  .75 


10  p.  BLAKISTON,  SON  &-  CO.'S 


EDWARDS.    Bright's    Disease.     How  a  Person  Affected  with  Bright's  Disease 

Ought  to  Live.     By  Jos.  F.  Edwards,  m.d.     2d  Ed.     Reduced  to        Cloth,  .50 

Constipation.     New  Edition.     Plainly  Treated  and  Relieved  Without  the  Use 

of  Drugs.     Second  Edition.     Price  Reduced.  Cloth,  .50 

Malaria:    What  It  Means;    How  to  Escape   It;  Its  Symptoms;  When  and 

Where  to  Look  Vor  li.    Price  Reduced.  Cloth,  .50 

Vaccination  and  Smallpox.     Showing  the  Reasons  in  favor  of  Vaccination, 

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FAGGE.  The  Principles  and  Practice  of  Medicine.  By  C.  Hilton  Fagge,  m.d., 
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and  Lecturer  on  Pathology  in,  Guy"s  Hospital ;  Senior  Physician  to  Evelina  Hos- 
pital for  Sick  Children,  etc.  Arranged  for  the  press  by  Philip  H.  Pye  Smith, 
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FENNER.     On  Vision.     Its  Optical  Defects,  the  Adaptation  of  Spectacles,  Defects  * 
of  Accommodation,  etc.     By  C.  S.  Fenner,  m.d.     With   Test  Types  and  74 
Illustrations.     Second  Edition,  Revised  and  Enlarged.     8vo.  Cloth,  $3.50 

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tions.    By  Samuel  Fenwick,  m.d.,      i2mo.  Cloth,  $1.25 
Atrophy  of  the  Stomach  and  Its  Effect  on  the  Nervous  Affections  of  the 
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FLAGG'S  Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities 
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Cavities  in  Teeth  of  all  Grades  of  Structure.     By  J.  Foster  Flagg,  d.d.s..  Pro- 
fessor in  the  Philadelphia  Dental  College.     8vo.     Second  Ed.  Cloth,  $4.00 

FLOWER'S  Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their 
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of  the  Cutaneous  Surface,  and  to  all  the  Muscles.  By  William  H.  Flower, 
F.R.C.S.,  F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator 
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FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
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FOTHERGILL.  On  the  Heart  and  Its  Diseases.  With  Their  Treatment.  In- 
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ment. In  all  72  large  colored  plates.  By  Tilbury  Fox,  m.d.,  f.r.c.p.,  Physi- 
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FRANKLAND'S  Water  Analysis.  For  Sanitary  Purposes,  with  Hints  for  the  In- 
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How  to  Teach  Chemistry.     Six  Lessons  to  Science  Teachers.     Edited  by 
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FULTON'S  Physiology.  A  Text-book.  By  J.  Fulton,  m.d.,  Professor  at  Trinity 
Medical  College,  Toronto.     Second  Edition,  Illustrated.     8vo.  Cloth,  $4.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  11 


GALLABIN'S  Midwifery.  A  Manual  for  Students  and  Practitioners.  By  A.  Lewis 
(.l.VLLAiiiN,  iM.D.,  K.R.C.P.,  Obstetric  Physician  to  Guy's  Hospital,  London,  and 
Professor  of  Midwifery  in  the  same  institution.     Illustrated.  In  Press 

GAMGEE.  Wounds  and  Fractures.  The  Treatment  of  Wounds  and  Fractures. 
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GARDNER'S  TECHNOLOGICAL  SERIES.  The  Brewer,  Distiller  and  Wine 
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GILL.  Indigestion :  What  it  is  ;  What  it  Leads  to  ;  and  a  New  Method  of  Treating 
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GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
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GLISAN'S  Modern  Midwifery.  A  Text-book.  By  Rodney  Glisan,  m.d.,  Emeritus 
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University,  Portland,  Oregon.     129  Illus.    8vo.  Cloth,  $4.00  ;  Leather,  $5.00 

GODLEE'S  Atlas  of  Anatomy.     Illustrating  most  of  the  Ordinary  Dissections  and 
many  not  usually  pi-acticed  by  the  Student.     With  References  and  an  Explana- 
tory Text,  and  48  Colored  Plates.     By  Rickman  John  Godlee,  m.d.,  f.r.c.S. 
A  large  Folio  Volume,  with  References,  and  a  Separate  Volume  of  Letter-press. 
The  two  Volumes,  Atlas  and  Letter-press,  Cloth,  ^20.00 

GOODHART  and  STARR'S  Diseases  of  Children.  The  Student's  Guide  to  the 
Diseases  of  Children.  By  J.  F.  Goodhart,  m.d.,  f.r.c.p..  Physician  to  Evelma 
Hospital  for  Children,  Demonstrator  of  Morbid  Anatomy  at  Guy's  Hospital. 
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GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
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Science,  Dental  Surgery  and  Dental  Mechanism,  in  the  Dental  Department  of 
the  University  of  Maryland.     Second  Edition.     Enlarged.     8vo.         Cloth,  I3.25 

GOWERS,  Spinal  Cord.     Diagnosis  of  Diseases  of  the  Spinal  Cord.    With  Colored 

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m.d.,  Ass't  Prof.  Clinical  Medicine,  University  College,  London.         Cloth,  $1.50 

Ophthalmoscopy.      A    Manual    and   Atlas    of    Ophthalmoscopy.      With    16 

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GRANVILLE.  Nerve  Vibration  and  Excitation  as  Agents  in  the  Treatment  of 
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GROSS'S  Biography  of  John  Hunter.  John  Hunter  and  His  Pupils.  By  S.  D. 
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GREENHOW.  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphy- 
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12  P.  BLAKISTON,  SON  6-  CO:S 


GREENHOW.    Addison's  Disease.     Illustrated  by  Plates  and  Reports  of  Cases. 

I5y  E.  Headlam  Greeniiow,  m.d.     8vo.  Cloth,  $3.00 

HABERSHON.  On  Some  Diseases  of  the  Liver.  By  S.  O.  Habershon,  m.d., 
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HALE.  On  the  Management  of  Children  in  Health  and  Disease.  A  Book  for 
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SANDY'S  Text-Book  of  Anatomy  and  Guide   to    Dissections.     For  the  Use  of 

Students.     By  W.  R.  Handy,  m.d.     312  Illustrations.     8vo.  Cloth,  ;g3.oo 

HARDWICKE.  Medical  Education  and  Practice  in  All  Parts  of  the  World. 
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HARLAN.  Eyesight  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d., 
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HARLEY.  Diseases  of  the  Liver,  With  or  Without  Jaundice.  Diagnosis  and 
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HARRIS'S  Principles  and  Practice  of  Dentistry.  Including  Anatomy,  Physi- 
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Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  of 
"Dictionary  of  Medical  Termmology  and  Dental  Surgery."  Eleventh  Edition. 
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"Dental  Medicine;"  Professor  of  the  Principles  of  Dental  Science,  Dental 
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Medical  and  Dental  Dictionary.  A  Dictionary  of  Medical  Terminology, 
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HEATH'S  Operative  Surgery.  A  Course  of  Operative  Surgery,  consisting  of  a 
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Text  of  Each  Operation.  By  Christopher  Heath,  f.r.c.s..  Holme  Professor 
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HIGGINS'  Ophthalmic  Practice.  A  Handbook  for  Students  and  Practitioners. 
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HILL  AND  COOPER.  Venereal  Diseases.  The  Student's  Manual  of  Venereal 
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JONES  and  SIEVEKING'S  Pathological  Anatomy.  A  Manual  of  Pathological 
Anatomy.  By  C.  Handfield  Jones,  m.d,  and  Edward  H.  Sieveking,  m.d. 
A  New  Enlarged  Edition.     Edited  by  J.  F.  Payne,  m.d.     IUus.  Cloth,  $5.50 

JONES.     Defects  of  Sight  and  Hearing,   their  Nature,  Causes  and  Prevention. 

By  T.  Wharton  Jones,  m.d.     Second  Edition.     i6mo.  Cloth,  .50 

KANE'S    Drugs    that    Enslave.      The   Opium,' Morphine,   Chloral,    and   Similar 

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KIRBY.  Selected  Remedies.  A  Pharmacopoeia  of  Selected  Remedies,  with 
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LANDIS'  Compend  of  Obstetrics  ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  Henry  G.  Landis,  m.d..  Professor  of  Obstetrics  and  Diseases 
of  Women,  in  Starling  Medical  College,  Columbus,  Ohio.  Second  Edition. 
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cine. By  Dr.  L.  Landois,  of  the  University  of  Greifswald.  Translated  from 
the  Fourth  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.sc.  Pro- 
fessor of  the  Institutes  of  Medicine  in  the  University  of  Aberdeen.  W^ith  very 
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LEWIN  on  Syphilis.  The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  15 

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scopical Examination  of  Air.  By  J.  D.  Macdonald,  m.d.  With  25  Litho- 
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MACKENZIE  on  the  Throat    and  Nose.    Complete.    Including  the  Pharynx, 
Larynx,    Trachea,    CEsophagus,   Nasal  Cavities,    etc.,    etc.     By  Morell  Mac- 
kenzie, M.D.,  Senior  Physician  to  the  Hospital  for  Diseases  of  the  Chest  and 
Throat,    Lecturer    on    Diseases    of   the   Throat    at   London    Hospital    Medical 
•     College,  etc. 

Vol.  L     Including  the  Pharynx,  Larynx,  Trachea,  etc.     112  Illustrations. 
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The  Pharmacopoeia  of  the  Hospital  for  Diseases  of  the  Throat  and  Nose. 
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MAC  MUNN.  On  the  Spectroscope  in  Medicine.  By  Chas.  A.  Mac  Munn,  m.d. 
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MADDEN.  Health  Resorts  for  the  Treatment  of  Chronic  Diseases.  The  result 
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to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d., 
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vised and  Improved,  Illustrating  the  Whole  Human  Body. 

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of  the  Textures. 

MARSHALL  &  SMITH.  On  the  Urine.  The  Chemical  Analysis  of  the  Urine. 
By  John  Marshall,  m.d.,  and  Prof.  Edgar  F.  Smith,  of  the  Chemical  Labora- 
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16  P.  BLAKISTON,  SON  &-  CO.'S 

MATTHIAS'  Leg^islative  Manual.  Rules  for  Conducting  Business  in  Meetings 
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MAYS'  Therapeutic  Forces  ;  or,  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
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Medical  College,  and  Professor  of  Anatomy  and  Clinical  Surgery  in  the  Penn- 
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MERRELL'S  Dig'est  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  17 

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Speech  and  Its  Defects.  Considered  Physiologically,  Pathologically  and 
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WILKES'  Pathological  Anatomy.    Lectures  on  Pathological  Anatomy.    By  Samuel 
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WILSON.     Human  Anatomy.     The  Anatomist's  Vade-mecum.     General  and  Spe- 
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long  descriptions  of  substances  and  theories  of  interest  only  to  the  advanced  chemi- 
cal student. 

PART  I — Treats  of  Light,  Heat  and  Electricity,  which  are  described  at  some  length,  and  explanations  made 
and  applied  to  common  phenomena.  In  the  subject  of  light,  only  so  much  is  given  as  will  explain  the  theory 
and  use  of  the  spectroscope.  In  electricity,  the  principal  aim  has  been  to  give  such  information  as  is  needed 
for  the  proper  understandinz,  worl<ing  and  care  of  th"-  medical  battery. 

PART  11 — Iheoretical  Chemistry.  Only  such  portions  of  the  well  established  principles  of  modem  chemistry 
as  are  necessary  to  an  understanding  of  the  subject  are  given  It  has  been  deemed  best  to  present  all  these 
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are  presented  in  a  concise,  clear  way,  in  a  logical  order  and  in  a  manner  which  the  author  has  found  specially 
siiccessful  in  an  experience  of  ovtr  twelve  years  of  teachii  g. 

PAR  1'  III — Treats  of  the  natural  history  of  the  elements,  of  their  principal  compounds,  with  their  physiological 
action  and  toxicology. 

PART  IV — Organic  liodies  commonly  used  in  medicine  and  pharmacy.  The  principal  organic  .substances 
derived  from  animal  life  are  given  a  place.  In  the  appendix  will  be  found  analyses  of  the  principal  secretions 
and  tissues,  tables  of  solubilities  and  oi  specific  gravities,  the  metric  system,  and  other  useful  information. 

Applied  Medical   Chemistry. 

Containing  a  description  of  the  apparatus  and  methods  employed  in  the  practice 
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BY  LAWRENCE  WOLFF,  M.D., 

Demonstrator  of  Chemistry  in  the  Jefferson  Medical  College  ;  Member  of  the  Philadelphia  College  of  Pharmacy 
and  of  the  Chemical  Section  of  the  Franklin  Institute,  etc. 

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medicinal  agents,  human  excretions,  secretions,  etc.,  without  elaborate  apparatus  or 
expensive  processes. 

Practical  and  Analytical  Chemistry. 

Being  a  complete  course  in  Chemical  Analysis,  for  pharmaceutical  and  medical 
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BY  HENRY  TRIMBLE,  Ph.G., 

Professor  of  Analytical  Chemistry  in  the  Philadelphia  College  of  Pharmacy. 

Illustrated.    8vo.    Cloth,  $1.50. 

SUMMARY  OF  CONTENTS.  Part  I.  Practical— Preparation  and  Properties  of  Gases,  Preparation  of  Salts, 
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Strontium,  Calcium,  Magnesium.  Group  III — Manganese,  Zinc,  Cobalt.  Nickel.  Group  IV — Iron,  Cerium, 
Chromium,  Aluminium.  Group  V — Arsenic,  Antimony,  Tin,  Gold,  Platinum.  Group  VI — Mercury  (ic). 
Bismuth,  Copper,  Cadmium.  Group  VII— Silver,  Mercury  (ous),  Lead.  Section  11 — Acids.  Section  III — 
Detection  of  Bases  and  Acids.  Section  IV — Some  of  the  Reactions  and  Tests  of  Purity  ol  the  more  import- 
ant Organic  Compounds.  Part  III.  Quantitative  Chemical  Analysis.  Section  I — Gravimetric  Estimation. 
Section  II — Volumetric  Estimation.     There  are  also  a  numoer  of  ixseful  Tables. 

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LONG  LIFE,  AND  HOW  TO  REACH  IT.  By  J.  G.  Richardson,  m.d.,  Professor 
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THE  SUMMER  AND  ITS  DISEASES.  By  James  C.  Wilson,  m.d..  Lecturer  on 
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EYESIGHT,  AND  HOW  TO  CARE  FOR  IT.  With  Illustrations.  By  Geo.  C. 
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Holden's  Manual  of  Anatomy. 

FIFTH  EDITION,  REVISED  AND  ENLARGED.    208  ILLUSTRATIONS. 
A  MANUAL  OF  THE  DISSECTIONS  OF  THE  HUMAN  BODY. 

By  Luther  Holden,  m.d.,  f.r.c.s.,  Consulting  Surgeon  to  St.  Bartholomew's  and  the 
Foundling  Hospitals,  London,  and  John  Langton,  f.r.c.s.,  Surgeon  to  and  Lec- 
turer in  St.  Bartholomew's  Hospital.  Fifth  Edition.  Revised  and  Enlarged,  with 
many  new  Illustrations.     Octavo.  Oil  Cloth  Binding,  $4.50 

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is  not  easily  soiled,  and  iiiay  be  washed  without  damage. 


DIAGRAM    or    AXILLA 
(From  Holden  s  Anatomy  ) 


1.  Axillary  Artbry. 

2.  Brachial  Akte.jy. 

3.  Thoracica  Humkkakia  Artery. 

4.  Superior  Thoracic  AKruriY 

5.  Subscapular  Arti-kv 

6.  DoRSALis  Scapula  Art';iiy 

7.  Posterior  Circumfu  x  Artery. 

8.  Superior  Profunda  Akt»hy. 

9.  Posterior  Thokach:  NtRVE. 

10.  Long  Suhscapulak   -..kvk. 

11.  Median  Nerve. 

12.  Cephalic  Vein. 

13.  MuSCULO-CUTANEOUS  NerVE. 

14.  Teres  Major. 

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striking  and  suggestive,  giving  more  at  a  glance  than  pages  of  text  description.  All  this  is  known  to  those  v^ho 
are  already  acquainted  with  this  admirable  work  ;  but  it  is  simple  justice  to  ils  value,  as  a  work  for  careful  study 
and  reference,  that  these  points  be  emphasized  to  such  as  are  commencing  their  studies.  The  text  matches  the 
illustrations  in  directness  of  practical  application  and  cWarness  of  detail." — Neiv  York  Medical  Record,  April 
iSth,  iSSS- 

BY   THE   SAME   AUTHOR. 

HUMAN  OSTEOLOGY.  Comprising  a  description  of  the  Bones,  with  Colored  Delinea- 
tions of  the  Attachments  of  the  Muscles.  The  General  and  Microscopical  Structure  of 
Bone  and  its  Development.  Carefully  Revised.  By  the  Author  and  A.  DoRAN,  F.R.C.S., 
with  Lithographic  Plates  and  Numerous  Illustrations.     Sixth  Edition.     8vo.     Cloth,  ^6.00 

HEATH'S  PRACTICAL  ANATOMY.     A  Manual  of  Dissections, 
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Watson  on  Amputations. 

Amputations  of  the  Extremities  and  Their  Complications.  By  B.  A.  Watson,  a.m  , 
M.D.,  Surgeon  to  the  Jersey  City  Chanty  Hospital,  to  St.  Francis'  and  to  Christ' j 
Hospital,  at  Jersey  City,  N.  J. ;  Fellow  of  the  American  Surgical  Association  ; 
Member  of  the  New  York  Pathological  Society,  etc.  Two  full-page  Colored 
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Pages.  Handsomely  bound  in  Cloth,  TS  50. 


SPECIMEN  OF   ILLUSTRATIONS   IN   WATSON's   AMPUTATIONS. 

"  This  volume  is  an  encyclopxdic  monograph,  containing  the  important  facts,  theories  and  arguments  relating 
to  amputations  of  the  extremities,  and  their  complications.  The  author's  aim  has  been  to  collect  facts  on  ihis 
subject  from  English,  French,  German  and  American  literature.  He  does  not  lay  claim  to  originality,  but,  of 
course,  introduces,  in  their  proper  places,  those  observations  which  his  own  experience  has  led  him  to  make  on 
the  general  subject.  Under  the  division  of  '  Complications,"  the  general  subject  of  the  treatment  of  wounds  is 
discussed,  with  an  outline  of  the  present  views  on  germs  and  germicides,  for,  in  the  words  of  the  preface,  the 
complications  of  amputation  wounds  are  essentially  the  same  as  those  which  pertain  to  any  solution  of  conlinui'y 
involving  the  various  tissues  of  the  body.  A  great  service  has  been  done  the  profession  by  the  insertion  o1  a 
translation  of  Gaupot's  and  Spellmann's  writings  on  artificial  limbs.  This  is  the  fullest  exposition  of  the  subject 
we  have  yet  seen  in  an  American  text-book.  Too  much  praise  cannot  be  given  to  the  typographical  appearance 
of  the  work.  The  illustrations  are  marvels  of  clearness,  and  do,  what  is  not  always  the  case,  elucidate  the  text." 
— Medical  Record,  New  Vork,  June  zoik,  iSSj- 

Pye's  Surgical  Handicraft. 

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Aural  Surgery,  Extraction  of  Teeth,  Ansesthetics,  etc.  By  Walter  Pye,  f.r.c.s., 
Surgeon  to  St.  Mary's  Hospital  and  the  Victoria  Hospital  for  Sick  Children  ; 
Examiner  in  Surgery  at  the  University  of  Glasgow.     208  Illustrations.     Octavo. 

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Heath's  Operative   Surgery. 

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Artist,  M.  Leveille,  of  Paris,  Engraved  on  Steel  under  his  immediate  superinten- 
dence, with  Descriptive  Text  of  Each  Operation,  and  numerous  Wood  Engravings. 
By  Christopher  Heath,  f.r.c.s.,  Surgeon  to  University  College  Hospital,  and 
Holme  Professor  of  Clinical  Surgery  in  University  College,  London.  One  Large 
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Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Polyclinic;  Consulting 
Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases,  and  Dermatologist 
to  the  Howard  Hospital.  With  colored  plates  representing  the  appearance  of 
various  lesions.     i2mo.  Cloth,  ^1.75 

*:^*  This  is  a  complete  epitome  of  skin  diseases,  arranged  in  alphabetical  order, 
giving  the  diagnosis  and  treatment  in  a  concise,  practical  way.  Many  prescriptions 
are  given  that  have  never  been  published  in  any  text-book,  and  an  article  incorporated 
on  Diet.  The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a  num- 
ber of  figures,  accurately  colored,  showing  the  appearance  of  various  lesions,  and 
will  be  found  to  give  great  aid  in  diagnosing. 

"  This  new  handbook  is  essentially  a  small  encyclopaedia.  *  «  «  Contains  a  very  complete  summary  of  the 
present  state  of  Dermatology.  *  *  *  We  heartily  commend  it  for  its  brevity,  clearness  and  evidently  careful 
preparation." — Pkiladelpkia  Medical  Times. 

'The  author  shows  a  proper  appreciation  of  the  wants  of  the  general  practitioner." — New  Va>  k  Medical 
Record. 

"  It  is  concisely  and  intelligently  written,  and  contains  many  of  the  best  formulas  in  use  for  the  various  forms 
of  Skin  Disease." — Neiu  York  Medical  Times. 

"  This  is  an  excellent  little  book,  in  which,  for  ease  of  reference,  the  more  common  diseases  of  the  skin  are 
arranged  in  alphabetical  order,  while  many  good  prescriptions  are  given,  together  with  clear  and  sensible  direc- 
tions as  to  their  proper  application." — Boston  Medical  and  Surgical  Journal. 

'  It  is  just  the  kind  of  book  that  the  general  practitioner  will  find  most  convenient  for  reference,  and  we  feel 
confident  that  it  will  be  appreciated." — Southern  Practitioner. 

RINDPLBISCH'S  PATHOLOGY.  The  Elements  of  Pathology.  By  Prof. 
Edward  Rindfleisch,  University  of  Wurzburg.  Authorized  translation  from 
the  first  German  edition,  by  Wm.  H.  Mercur,  m.d.  (Univ.  of  Pa.)  Revised  by 
James  Tyson,  m.d  ,  Professor  of  Pathology  and  Morbid  Anatomy  in  the  Univer- 
sity of  Pennsylvania.     i2mo.  Cloth,  ^2.00 

Pro/.  Tyson,  in  his  Pre/ace  to  the  American  edition,  says: — "A  high  appreciation  of  Prof.  Rindfleisch's 
work  on  Pathological  Histology,  caused  me  to  make  careful  examination  of  these  '  Elements'  immediately  after 
their  publication  in  the  original.  From  such  an  examination  I  became  satisfied  that  the  book  would  fill  a  niche 
in  the  wants  of  the  student,  as  well  as  of  others  who  may  desire  to  familiarize  themselves  with  general  patho- 
logical processes,  viewed  from  the  most  modern  standpoint." 

BRUBN'S  PHYSICAL  DIAGNOSIS.  Second  Edition.  A  Pocket-book 
of  Physical  Diagnosis  of  the  Heart  and  Lungs ;  for  the  Student  and  Physician. 
By  Edward  T.  Bruen,  Demonstrator  of  Clinical  Medicine  in  the  University  of 
Pennsylvania ;  Lecturer  on  Pathology  in  the  Women's  Medical  College  of  Phila- 
delphia ;  2d  Edition,  revised,  with  new  original  illustrations.     i2mo.     Cloth,  $1.50 

"  We  consider  the  description  of  the  manner  and  rules  governing  the  art  of  percussion  well  given.  The  sub- 
ject is  always  a  difficult  one  for  beginners,  and  requires  to  be  well  handled  in  order  to  be  properly  understood." 
— .American  yournal  o/ Medical  Sciences. 

WOAKES  ON  CATARRH  AND  DISEASES  OP  THE  NOSE  CAUS- 
ING DEAFNESS.  By  Edward  Woakes,  m.d..  Senior  Aural  Surgeon  to 
the  London  Hospital  for  Diseases  of  the  Throat  and  Chest.  29  Illustrations. 
i2mo.  Cloth,  ^1.50 

"  Out  of  the  large  number  of  special  works  on  catarrh,  there  is  none  for  which  we  have  such  an  unqualified 
good  opinion.     *     *    *     The  subject  is  clearly  presented.    •    •    •    The  line  of  treatment  suggested  is  rational. " 

—North  Car  ■•1171.1  Medical  yournal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


PRACTICAL  HANDBOOKS— Continued. 

VON  ARLT.  DISEASES  OF  THE  EYE.  Including  those  of  the  Con- 
junctiva, Cornea,  Sclerotic,  and  of  the  Iris  and  Ciliary  Body.  By  Dr.  Ferdi- 
nand RiTTER  VON  Aklt,  Professor  of  Ophthalmology  in  Vienna.  Translated 
by  Lyman  Ware,  m.d..  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary  ; 
Ophthalmic  Surgeon  to  the  Presbyterian  Hospital,  and  to  the  Protestant  Orphan 
Asylum,  Chicago.     Illustrated.     8vo.     325  pages.  Cloth,  $2.50 

"  His  style  is  condensed  but  clear,  and  his  pages  contain  a  vast  amount  of  information,  couched  in  such  lan- 
guage that  it  will  be  equally  instructive  to  the  general  practitioner  and  the  specialist." — Philadelphia  Medical 
and  Surgical  Reporter,  May  30th,  tS'iS- 

TYSON  ON  THE  URINE.  A  Practical  Guide  tc  the  Examination  of  Urine. 
For  the  Use  of  Physicians  and  Students.  With  Colored  Lithographic  Plates  and 
Numerous  Illustrations  Engraved  on  Wood.    Fourth  Edition.    i2mo.    Cloth,  Ji. 50 

"  The  practical  man  will  find  in  this  little  book  all  that  is  absolutely  necessary  for  him  to  knov/,  in  order  to 
utilize  fully  the  data  supplied  by  the  urine." — Chicago  Medical  Journal. 

GILLIAM'S  ESSENTIALS  OP  PATHOLOGY.  The  Essentials  of  Path- 
ology. By  D.  Tod  Gilliam,  m.d.,  Professor  of  Physiology,  Starling  Medical 
College,  Columbus,  Ohio.     With  47  wood  engravings.     i2mo.  Cloth,  $2.00 

"The  general  practitioner  will  find  in  this  little  i2mo  a  convenient  compendium  of  the  current  pathology  of 
the  day." — Chicago  Medical  Journal  and  Examiner. 

THE  PRACTICAL  SERIES. 

A  NEW  VOLUME  JUST  READY. 

*^*  The  volumes  of  this  series  written  by  well  known  physicians  and  surgeons,  of 
large  private  and  hospital  experience,  recognized  authorities  on  the  subjects  of  which 
they  treat,  will  embrace  the  various  branches  of  medicine  and  surgery.  They  are  of 
a  thoroughly  practical  character,  calculated  to  meet  the  requirements  of  the  practi- 
tioner, and  will  present  the  most  recent  methods  and  information  in  a  compact  shape 
and  at  a  low  price.     Bound  uniformly,  in  a  handsome  and  distinctive  cloth  binding. 

DISEASES  OF  THE  KIDNEYS,  AND  URINARY  DERANGE- 
MENTS. By  C.  H.  Ralfe,  m.a.,  m.d.,  f.r.c.p.,  Assistant  Physician  to  the 
London  Hospital;  late  Senior  Physician  to  the  Seamen's  Hospital,  Greenwich. 
i2mo.     With  Illustrations.     572  pages.     Just  Ready.  Cloth,  $2.75 

BODILY  DEFORMITIES  AND  THEIR  TREATMENT.  A  Handbook 
of  Practical  Orthopaedics.  By  H.  A.  Reeves,  f.r.c.s.,  Senior  Assistant  Surgeon 
and  Teacher  of  Practical  Surgery  at  the  London  Hospital;  Surgeon  to  the  Royal 
Orthopaedic  Hospital,  etc.     i2mo.     228  Illustrations.     460  pages.        Cloth,  $2.25 

"  From  what  we  have  already  said,  it  will  be  seen  that  Mr.  Reeves  has  given  us  a  trustworthy  guide  for  the 
treatment  of  a  very  extended  class  of  cases.  «  *  *  If  the  other  volumes  of  the  Practical  Series  are  as  good 
as  this,  we  shall  be  agreeably  disappointed  " — American  Journal  o/ Medical  Sciences,  April,  j88S- 

"  The  utility  of  the  work  now  before  us  cannot  be  better  recommended  to  the  appreciation  of  the  professional 
reading  public,  than  by  recalling  that  it  is  the  first  of  its  kind,  dealing  with  orthopjcdics  from  a  modem  stand- 
point."— Hospital  Gazette  and  students'  Journal. 

DENTAL  SURGERY  FOR  GENERAL  PRACTITIONERS  AND 
STUDENTS  IN  MEDICINE.  By  Ashley  W.  Barrett,  m.d,,  m.r.c.s. 
Eng.,  Surgeon-Dentist  to,  and  Lecturer  on  Dental  Surgery  and  Pathology  in  the 
Medical  School  of,  London  Hospital.     i2mo.     Illustrated.  Cloth,  ^i. 00 

"  Replete  with  an  abundance  of  practical  information  of  unquestionable  utility."— //asp ital  Gazette  and 
Students'  Journal.  .  , 

"  The  object  of  this  volume  is  to  present  the  student  and  practitioner  with  a  clear,  concise  and  systematic 
account  of  urinary  pathology  and  therapeutics,  based  upon  the  latest  ascertained  facts,  and  supported  by  the  best 
authorities.  Throughout,  the  author  has  endeavored  to  put  prominently  forward  the  characters  upon  which  the 
diagnosis  of  the  various  renal  and  urinary  diseases  is  founded,  and  their  treatment  indicated.  —  E^ttr act  from 
The  Pre/ace. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


GOODHART  AND  STARR 

ON 

The  Diseases  of  Children. 

A  Manual  for  Students  and  Physicians.  By  J.  F.  Goodhart,  m.d.,  Thysician  to  the 
Evehna  Hospital  for  Children  ;  Assistant  Physician  to  Guy's  Hospital,  London. 
American  Edition,  Revised  and  Edited  by  Louis  Starr,  m.d..  Clinical  Professor 
of  Diseases  of  Children  in  the  Hospital  of  the  University  of  Pennsylvania, 
and  Physician  to  the  Children's  Hospital,  Philadelphia.  Containing  many  new 
Prescriptions,  a  list  of  over  50  Formulae,  conforming  to  the  U.  S.  Pharmacopoeia, 
and  Directions  for  making  Artificial  Human  Milk,  for  the  Artificial  Digestion  of 
Milk,  etc. 

Just  Ready.    Demi- Octavo.    738  Pages.    Cloth.  $3.00:  Leather.  $4.00. 

The  New  York  Medical  Record,  for  May,  1885,  says : — 

"As  it  is  said  of  some  men,  so  it  might  be  said  of  some  booVs,  that  they  are  'born  to  greatness.'  This  new 
volume  has,  we  believe,  a  mission,  particularly  in  the  hands  of  the  younger  members  of  the  profession.  Jn  these 
days  of  prolixity  in  medical  literature,  it  is  refreshing  to  meet  with  an  author  who  knows  both  what  to  say  and 
when  he  has  said  it.  The  work  of  Lir.  Goodhart  (admirably  conformed,  by  Dr.  Starr,  to  meet  American  require- 
menLs)  is  the  nearest  approach  to  clinical  teaching  without  the  actual  presence  of  clinical  material  that  we  have 
yet  seen.  It  does  not  discuss  mooted  questions  of  Pathology,  but  is  a  terse,  straightforward  account  of  the 
author's  experience  at  the  bedside  of  ailing  children.  Domestic  hygiene  is  awarded  its  important  place  in  the 
therapeutics  of  pediatrics.  The  details  of  management  so  gratefully  read  by  the  young  practiiioner  are  fully 
elucidated.     Altogether,  the  book  is  one  of  as  gieat  practical  working  value  as  we  have  setn  for  many  months." 

From  the  Journal  of  the  American  Medical  Association,  June  6th,  1885. 

"  Nothing  that  concerns  disease  as  found  in  childhood  seems  to  have  escaped  the  author's  attention.  From 
introduction  to  the  end  it  is  replete  with  valuable  information,  and  one  reads  it  with  the  feeling  that  Dr.  Good- 
hart is  writing  of  what  he  has  seen  at  the  bedside.  It  need  scarcely  be  added  that  the  revisions  and  additions  by 
the  American  editor  are  of  much  value,  neither  too  full  nor  too  spare,  and  very  judicious." 

From  the  Boston  Medical  and  Surgical  Journal,  June  4th,  1885. 

"  This  work  is  written  in  a  very  agreeable  style,  carrj'ing  weight,  from  its  simplicity  and  clearness,  and  the 
evidently  large  and  matured  experience  of  the  author.  It  is  especially  adapted  to  the  needs  of  the  practicing 
physician  raiher  than  for  the  medical  student,  as  with  rare  discernment  it  takes  up  important  points  in  the  details 
of  the  disease  and  deals  with  them  practically,  leaving  the  general  typical  course  of  the  case  to  the  other  numerous 
writers  who  have  already  covered  the  ground  in  this  class  cf  esses.  The  type  and  paper  are  especially  to  be 
commended,  and  the  editor.  Dr.  Starr,  can  be  said  to  have  offered  a  very  attractive  book  to  the  medical  profession." 

h 
From  the  London  Medical  Times  and  Gazette,  March  7th,  1885. 

"Among  the  great  superfluity  of  medical  books  which  issue  from  the  press  we  are  occasionally  gladdened  by 
the  reading  of  seme  which  rot  only  have  an  unquestionable  raison  d'  Hre,  but  also  as  certainly  fulfill  their 
jiurpose.  Such  a  book,  we  do  not  hesitate  to  say,  is  that  which  is  now  before  us  ;  and,  afier  a  careful  perusal, 
productive  of  both  pleasure  and  profit,  we  can  assure  Dr.  Goodhart  that  he  owes  no  apology  for  his  work,  and 
that  if,  as  he  eays,  he  has  repeated  tales  that  have  leen  told  before,  he  has  repeated  ihem  with  'excellent 
differences.'  The  book  cannot  be  abstracted.  It  must,  and  we  think  will,  be  read  by  all  who  are  interested 
in  or  desire  to  study  its  subject.  We  feel  sure,  moreover,  and  this  forcibly  struck  us  while  reading  through  the 
work,  that  those  practitioners  who  have  given  even  half  the  thcught  and  study  to  the  subject  of  the  diseases  of 
children  that  Dr.  Goodhart  has  done,  will  be  able  to  endorse  the  bulk  of  his  leaching,  and  will  recognize  very 
many  of  their  own  unwritten,  and  sometimes  unspoken,  thoughts  and  beliefs;  an  evidence  at  once  of  the  great 
value  of  the  book,  and  an  explanation  of  the  undoubted  pleasure  that  every  expert  and  earnest  student  will 
inevitably  experience  in  its  perusal." 


OTHER  WORKS  ON  DISEASES  OF  CHILDREN : 

DAY.  DISEASES  OF  CHILDREN.  A  Practical  and  Systematic  Treatise 
for  Practitioners  and  Students.  Second  Edition.  Rewritten  and  very  much 
Enlarged.     8vo.     752  pp.  Cloth,  $3.00;  Sheep,  M-OO 

MEIGS  AND  PEPPER  ON  CHILDREN.  A  Practical  Treatise  on  the  Dis- 
eases of  Children.     Seventh  Edition,  thoroughly  Revised  and  Enlarged. 

Cloth,  0.OO;  Leather,  $7.00 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


?  QUIZ-COMPENDS  ? 

A  NEW  SErUZS  OF  PEACTICAL  MANUALS  FOS  THE    PHYSICIAN  AND  STUDENT. 

Compiled  in  accordance  7i>ith  the  latest  teacliim^s  of  prominent  lecturers 

and  the  most  popular  7'ext-  books. 

They  form  a  most  complete  set  of  Compends,  containing  information  nowhere  else- collected 
in  such  a  condensed,  practical  shape.  The  authors  have  had  large  experience  as  cjuiz  masters 
anil  attaches  of  colleges,  with  exceptional  opportunities  for  noting  the  most  recent  advances  in 
therapeutics,  methods  of  treatment,  etc.  The  arrangement  of  the  subjects,  illustrations  and 
types,  are  all  of  the  most  improved  form,  and  the  size  of  the  books  is  such  that  they  may  be 
easily  carried  in  the  [xjcket. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 


No.  I.  Human  Anatomy.  Third  Edi- 
tion. Illustrated.  Hy  Samuel  O.  L. 
I'orrER,  M.A..  M  D.,  late  A.  A.  Surgeon  U. 
S.  Army.     With  63  lUus.     3d  Revised  Ed. 

"To  those  desiring  to  post  themselves  hurriedly  for 
examination,  this  little  book  will  be  useful  in  refreshing 
the  memury." — AV:t/  Orleans  Med.  and  Surg.  Jt. 

Nos.  2  and  3.  Practice  of  Medicine. 
Especially  adapted  to  the  use  of  Students 
and  Physicians.  By  Daniel  E.  HucH'iS, 
M.D.,  Demonstrator  of  Clinical  Medicine  in 
Jefferson  Med.  College,  Phila.     In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodica'  Fev- 
ers, Diseases  of  ihe  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including Tests 
for  Urine),  General  Diseases,  etc. 

P.ART  11. — Diseases  of  the  Respiratorj'  System  (in- 
cluding Physical  Diagnosis),  Circulatorj'  System  and 
Nervous  System  ;   Disea.ses  of  the  Blood,  etc. 

*j,*  These  litile  books  can  be  regarded  as  a  full  set  of 
notes  upon  the  Practice  of  Medicine,  contaii.ing  the 
Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis, 
Diagnosis.  Treatment,  etc.,  of  eacfi  disease,  and  includ- 
ing a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embry- 
ology. Second  Edition.  By  Ali;krt  P. 
Bruraker.m.d.,  Prof,  of  Physiology,  Penn'a 
College  of  Dental  Surgery;  Demonstrator 
of  Physiology  in  Jefferson  Med.  College, 
Phila.  Revised  and  Enlarged. 
"  This  is  a  well  written  little  book." — London  Lancet. 

No.  5.  Obstetrics.  Illustrated.  Second 
Edition.  For  Physicians  and  Students. 
By  Henry  G.  Landis.  M.n.,  Prof,  of  Ob- 
stetrics and  Diseases  of  Women,  in  Starling 
Medical  College,  Co.'umbus.  Revised  Ed. 
New  Illustrations. 

"  We  have  no  doubt  that  many  students  will  find  in 
it  a  most  valuable  aid."' —  The  Amer.  Jl  o/  Ol/xtctrics. 

No.  6.  Materia  Medica  and  Therapeu- 
tics. Second  Revised  Edition.  With 
especial  Reference  to  the  Phy.siological  .\c- 
tions  of  Drugs.  For  the  use  of  Medical, 
Dental  and  Pharmaceutical  Students,  and 
Practitioners.  Based  on  the  New  Revision 
(Sixth)  of  the  U.  S.  Pharmacopoeia,  and 
including   many  unofficinal  remedies.     B: 


Samuel  O.  L.  Potter,  m.a.,  m.d.,  late  A. 
A.  Surg.  U.  vS.  Army.  Revised  Edition, 
with  Index. 

"  One  of  the  very  best  we  have  ever  seen." — Southern 
Clinic. 

No.  7.  Inorganic  Chemistry.  New  Edi- 
tion. By  G.  Masmn  Ward,  m.u..  Demon- 
strator of  Chemistry  in  Jefferson  Med.  Col- 
lege, Phila.  Including  Table  of  Elements 
and  various  Analytical  Tables.     New  Ed. 

"  This  neat  pocket  volume  is  a  brief  but  excellent 
compend  of  inorganic  chemistry  and  simple  analysis  of 
the  metals." — Pharmaceutical  Record,  A'.   J'. 

No.  8.  Visceral  Anatomy.  Illustrated. 
By  S.amuel  O.  L.  Potter,  m.a.,  m.d.,  late 
A.  A.  Surg.  U.  S.  Army.     With  40  Illus. 

"  Worthy  our  recommendation  to  students,  and  a 
ready  reference  to  the  busy  practitioner." — Chicago 
Med.  Times. 

No.  9.  Surgery.  Second  Edition.  Illus- 
trated. Including  P'ractures,  Wounds, 
Dislocations,  Sprains,  .\mputations  and  other 
operations;  Inflammation,  Suppuration,  Ul- 
cers, Syphilis,  Tumors,  Shock,  etc.  Dis- 
eases of  the  Spine,  Ear,  Eye,  Bladder,  Tes- 
ticles, Anus,  and  other  Surgical  Diseases. 
By  Orville  Horwitz,  a.m.,  m.d..  Resident 
Physician  Pennsylvania  Hospital,  Phil'a. 
Second  Edition,  Revised  and  Enlarged. 
With  62  Illustrations. 

"Will  prove  very  useful,  both  to  the  student  and 
practirioner." — I'alentine  Mult,  M.D.,  Ass't  to  the 
Prof.  ,/ Surgery,  BelU-Z'ue  Hoi/'itul,  Xexv  i\^rk. 

No.  10.  Organic  Chemistry.  Including 
Medical  Chemistry,  Urine  Analysis,  and  the 
Analysis  oC  Water  and  Food,  etc.  By  Henry 
Leffm.ann,  M.U.,  Demonstrator  of  Chemis- 
try in  Jefferson  Med.  College;  Prof,  of 
Chemistry  in  Penn'a  College  of  Dental 
Surgery,  Philadelphia. 

"Tt  is  a  useful  and  valuable  addition  to  the  series  of 
Quiz-Compcnds." — Cvllrge  and  Clinical  Record. 

No.  II.  Pharmacy.  By  Y.  E.  Stewart, 
M.D.,  PH.G ,  Quiz  Master  at  Philadelphia 
College  of  Pharmacy. 


Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

^^  'I'/'use  i'Oflis  tire  loitsUinti'y  rertsfd'  to  kt,-p  tip  with  the  LUeU  tciiihiri^s  avd  iiis.ex-efies. 

P.    BLAKISTON,  SON   &  CO.,   1012  Walnut  St.,  Philadelphia. 


The  Physician's  Visiting  List. 

(LINDSAY  &  BLAKISTON'S.) 
PUBLISHED  ANNUALLY;    NOW  IN  ITS    THIRTY-FIFTH   YEAR. 

Containing  Calendar,  List  of  Poisons  and  Antidotes,  Dose  Tables  rewritten  in  accord- 
ance  with  the  Sixth  Revision  of  the  U.  S.  Pharmacopoeia,  Marshall  Hall's  Ready 
Method  in  Asphyxia,  Lists  of  New  Remedies,  Sylvester's  Method  for  Producing 
Artificial  Respiration,  with  Illustrations;  Diagram  for  Diagnosing  Diseases  of 
Heart  and  Lungs ;  a  new  Table  for  Calculating  the  Period  of  Utero-Gestation,  etc. 

8®=°  The  Quality  of  the  Leather  used  in  Binding  this  List  has  been  again  Improved,  and  a 
Superior  Pencil,  with  Nickel  Tip,  manufactured  especially  for  it,  has  been  added. 

SIZES    AND    PRICES. 

For  25  Patients  weekly.  Tucks,  pockets,  etc.,  ;^i.oo 

50       "  "  "            "  1.25 

75       "  "  "            '*  1.50 

100       "  "  "            "  2.00 

ci  II  17-  1                O^i^-  to  Tune") 

5°       "  "  2^01^-             ]  July  to  Dec.  I  "-5° 

,,  ,#  -17  1                f  Jan.  to  June  1 

^°°       "  "  ^^°^^-             i  July  to  Dec.  I  3-oo 

INTERLEAVED    EDITION. 

For  25  Patients  weekly.  Interleaved,  tucks,  etc.,   1.25 

50       "■  "  •  "  "  1.50 

,,  ,1  ^T  ^  f  Jan.  to  June  ] 

CO       "  *'       2  Vols.  i  T  1     *    in,       ^  3- 00 

-)  ( July  to  Dec.  3  -^ 

Perpetual  Edition,  without  Dates,  can  be  commenced  at  anytime  and  used  until  full,  similai 
in  style,  contents  and  arrangements  to  the  above. 

For  25  Patients,  Interleaved,  ^1.25 
"    50         "  "  1.50 

"For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  by  nofte  in  the  market." — iV.  K. 
Medical  Kecord. 

"The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published."— 
Canada  Medical  and  Surgical  yourjtal, 

"  After  all  the  trials  made,  there  are  none  superior  to  it." — Gaillard' s  Medical  yournal. 

"  It  has  become  Standard.'" — Southern  Clinic. 

"  Regular  as  the  seasons  comes  this  old  favorite." — Michigan  Medical  News. 

"  It  is  quite  convenient  for  the  pocket,  and  possesses  every  desirable  quality." — Medical  Herald. 

"The  most  popular  Visiting  List  extant.'' — Buffalo  Medical  and  Surgical  yournal. 

"  We  have  used  it  for  years,  and  do  not  hesitate  to  pronounce  it  equal,  ifnot  superior,  to  any." — Southern  Clinic. 

"This  Visiting  List  is  too  well  known  to  require  either  description  or  commendation  from  us." — Cincinttati 
Medical  News. 

WATSON'S 

Physician's   Ledger   and   Cash   Book  Combined. 

WEEKLY  AND  MONTHLY. 

This  Ledger  is  based  upon,  and  designed  to  be  used  in  connection  with,  Lindsay  & 
Blakiston's  Physician's  Visiting  List. 

PRICES. 

Ledger  for  1000  accounts,  Leather,  56.50' 

"           500         "  "          5.00 

"           500         "  Cloth,    4.00 

*»*  Sample  pages  of  both  books  sent  upon  application.  Books  sent,  postage  pre- 
paid, upon  receipt  of  full  price,  or  can  be  obtained  through  any  bookseller. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


COLUMBIA  UNIVERSITY 

This   book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

AUG      3   ^oo 

1 

l\i  "    ;     ,. 

OCTl 

Wf.^ 

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C2e(638IM50 

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